A Manual For Implementation: Workload Indicators of Staffing Need (WISN)

WHO/HRB/98.
2
Distr.: Limited
English only
Workload indicators of staffing need (WISN)
A manual for implementation
World Health Organization

Division of Human Resources Development and Capacity Building
Geneva, Switzerland
1998
WHO/HRB/98.2
Distr.: Limited
English only
Workload indicators of staffing need (WISN)

A manual for implementation
Prepared for the World Health Organization

by
Peter J. Shipp
Initiatives Inc.
Boston
USA
World Health Organization

Division of Human Resources Development and Capacity Building
Geneva, Switzerland
1998
Acknowledgements
The manual Workload Indicators of Staffing Need (WISN) has been developed and field-tested by
the World Health Organization with financial support through the voluntary contribution from the
Government of Japan to the Division of Human Resources Development and Capacity Building.
Its contribution is greatly appreciated.
© World Health Organization
This document is not issued to the general public, and all rights are reserved by the World Health Organization (WHO). The document
may not be reviewed, abstracted, quoted, reproduced or translated, in part or in whole, without the prior written permission of WHO. No
part of this document may be stored in a retrieval system or transmitted in any form or by any means - electronic, mechanical or other -
without the prior written permission of WHO.
The views expressed in documents by named authors are solely the responsibility of those authors.
Table of contents
Introduction ......................................................................................................................................... 1
Section A – The WISN method and its uses ...................................................................................... 3
1. The need for a new method ......................................................................................................... 3
2. The basis of the WISN Method................................................................................................... 5
3. Features of the WISN Method .................................................................................................... 6
4. How the WISN Method works: differences and ratios ............................................................. 11
5. Using the WISN Method: identifying priority situations .......................................................... 12
6. Using the WISN Method: improving the current staffing situation .......................................... 13
7. Using the WISN Method: human resource management and planning .................................... 18
8. The constraints and limitations of the Method .......................................................................... 19
Section B – Steps in design and implementation of the method ...................................................... 23

1. Starting the process: setting the objectives ............................................................................... 23
2. Choosing the basic design of the procedure to be implemented ............................................... 26
3. Setting up the implementation group ........................................................................................ 28
4. Procedure for establishing standards of professional performance ........................................... 31
5. Mobilizing commitment to the WISN Method ......................................................................... 32
6. Collecting and handling the data ............................................................................................... 32
7. Plan and budget for operating the new procedure in regular use .............................................. 34
8. Workplan and budget for implementation ................................................................................ 35
Section C – Technical factors........................................................................................................... 37

1. Determining available working time per year ........................................................................... 37
2. Setting Activity Standards ........................................................................................................ 43
3. Turning Activity Standards into Standard Workloads .............................................................. 56
4. Using standard workloads and allowance standards to calculate staffing requirements ........... 61
5. Computerization of the WISN calculations .............................................................................. 67
Annex A – Staffing requirements for time-specified posts ……………………………………… 69
Annex B – Instructions for groups which are setting activity standards ………………………… 71
Section D – Examples of WISN activity standards already used

for individual staff categories ........................................................................................................... 77
____________________________________________________________________________________________________________________ Introduction
Introduction
This Manual sets out all the activities which are necessary in order to design and implement the
WISN Method in a country. The material in this Manual is based on the experience and results of
implementing the WISN Method in Papua New Guinea (supported by the Asian Development
Bank), in the United Republic of Tanzania (supported by DANIDA through WHO), in Kenya
(supported by USAID); in Sri Lanka (supported by the World Bank); and also in six other
countries: Bahrain, Egypt, Hong Kong, Oman, Sudan and Turkey which participated in a field trial
of an early draft of this Manual (supported by WHO headquarters and the WHO Regional Office
for the Eastern Mediterranean).
The Manual is divided into four sections:
Section A – The WISN method and its uses

A description of the principles and the main policy/management uses of the method. This section
has two main purposes. First, it provides an overall picture or context for those who will design
and set up the procedure, so that they can better understand how the different tasks contribute to
the overall result. Second, it provides material which can be used to explain to potential users of
the results, and to others who will be involved in the implementation, how the method operates and
how it can be used to improve their work.
Section B – Steps in design and implementation of the method

How to carry out the implementation of the method. The section describes a step-by-step
procedure for designing and installing the WISN Method and how these may be fitted together into
an overall work plan for the implementation exercise.
Section C – Technical factors

How to deal with the technical/mathematical aspects of the method. This section covers the setting
of activity (time) standards for government health staff, how to translate these into standard
(annual) workloads for use in the WISN calculations, the calculation procedures to be used, and
the use of computers in performing the calculations and producing tables of results.
Section D – Examples of WISN activity standards already used for individual staff
categories
This section lists the Activity Standards which have been used for staff categories and
subcategories in countries which have either implemented the WISN Method or which for other
reasons have set Activity Standards for their health staff. Because conditions and circumstances
vary so much from one country to another, these figures are offered for guidance only.
In normal circumstances, a “Manual for Implementation” like this is of interest and comes into use
only when a decision has already been made to undertake an exercise to implement a new
procedure. However, the WISN Method is novel, it produces information which has not been
available before now, and it is based on a principle (setting activity times or standards for health
staff) which has not been used in health services, although it has been widely employed in
manufacturing and commercial organizations for many years. The senior staff concerned may well
find that they require information about the basis of the method, its operation, its results and their
uses before they can come to the initial decision on whether to implement the method.
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Workload indicators of staffing need – A manual for implementation _________________________________________________________________________
Although this document covers all the normal requirements for a Manual of Implementation, it also
takes account of this unusual situation where the method is entirely novel. The material in sections
A and B is set out so that it can be summarized and/or edited in order to provide decision-makers
with the background information on how the WISN Method works and how the results can be used,
should this be necessary, in order to help them take the initial decision on whether to implement
the method. This material can also be used to prepare presentations for managers, administrators
and others who will be the eventual users of the method and its results.
2 __________________________________________________________________________________________
__________________________________________________________________________________________ Section A – The WISN method and its uses
Section A:
The WISN method and its uses
This section sets out a description of the principles on which the WISN Method is based, what
information it can produce, and how this information can be used by health managers and
administrators in order to improve the current health personnel situation, for example, how to
deploy the available health staff more effectively, and also how to plan for future improvements
in services and in human resource management.
Contents
1. The need for a new method ................................................................................................ 3
2. The basis of the WISN Method .......................................................................................... 5
3. Features of the WISN Method ............................................................................................ 6
4. How the WISN Method works: differences and ratios.................................................... 11
5. Using the WISN Method: identifying priority situations ................................................ 12
6. Using the WISN Method: improving the current staffing situation ................................ 13
7. Using the WISN Method: human resource management and planning .......................... 18
8. The constraints and limitations of the Method ................................................................. 19
1. The need for a new method

For many years there has been a need for a rational method of setting the correct staffing levels in
health facilities. In earlier decades, when developing countries first addressed the issues of human
resource planning and management in their health services, they used population ratios (numbers
of doctors, nurses, etc. per 1,000 population). For a time this was sufficient to tackle the major
problem of the period - assessing the overall staffing requirements and the training loads for health
services in the country. Later, attention naturally shifted to the more detailed question of the
staffing of individual health facilities, and standard staffing schedules were used (fixed patterns of
staff for health posts, health centres, district hospitals, etc. in the country). While both these
methods were useful in their time, they have serious disadvantages. Population ratios do not
distinguish between the employment of health staff in the different services in an area, for example,
the numbers of nurses who should be employed in referral hospitals, district hospitals, health
centres, health posts, etc. With standard staffing schedules the distribution of the facilities
themselves is also a major factor; for example, a district may have well-staffed facilities, but far
too few of them.
But most important, these methods do not take account of the wide local variations which are found
within every country, such as the different levels and patterns of morbidity in different locations,
the ease of access to different facilities, the patient attitudes in different parts of the country to the
services provided, and the local economic circumstances. All these factors considerably affect the
demand for services in an area and at individual facilities, and therefore they affect the staffing
levels actually required to meet the demand. The WISN Method frequently shows that staffing
requirements vary widely between health facilities of the same type, according to their workloads.
Staffing norms based on population ratios or standard staffing schedules are usually set somewhere
in the middle of this range. This leads to overstaffing in some facilities and under staffing in
_________________________________________________________________________________________ 3
others. Those facilities which are unable to cope with their workloads (because they have only the
staffing norms or standard staffing schedules) apply for more staff, and frequently get an increase
because the request is in fact justified. Once this precedent has been established, other facilities
also seek staff increases even though their staffing levels are in fact adequate for their workloads.
Thus the authority of the norms or standard staffing schedules disappears and their value in
personnel management and control is lost.
Health administrators have long sought a method of calculating health staffing requirements which
does not have these disadvantages. Furthermore, as national health staffing establishments and
training volumes have been brought under some degree of control, health administrators have been
turning their attention to further issues, for example, the optimal deployment of staff, particularly
to rural areas; the equitable deployment of staff in accordance with the demands actually
experienced; and the optimal determination of staff categories, particularly with a view to reducing
the large number of staff categories found in some countries.
In many countries ministries of health are experiencing a double pressure. On the one hand there
is a strengthening popular demand for better health services to an ever-increasing population,
coupled with a stronger and more detailed interest from the population at large (and particularly
in the national news media) in both the performance of the country's health services and the equity
of its distribution. On the other hand, resources for health are at best increasing slowly; in most
countries they are at a standstill or even reducing. Certainly resources are not keeping pace with
the increase in demand. Health administrators must attempt to achieve maximum coverage of
services (extending into the rural and remote areas where the unit costs of service delivery are
higher) with greater impact (by improving current effectiveness levels), equity in the provision of
services (i.e. overall staffing deployment according to demand) and economy of operation (in staff
categories, numbers and mix).
Until now there has been no technique available which will calculate:
- the optimal allocation and deployment of current staff geographically, i.e. allocating staff to
provinces within a country, districts within a province, areas within a district, and so on,
according to the volume of services which are being delivered and the different types of health
staff which are required to deliver these services;
- the optimal allocation and deployment of current staff functionally, i.e. allocating staff between
the different types of health facilities or different health services in the country as a whole, in
a province, in a district, in an area, etc., according to the volume of services which are being
delivered and the different types of health staff which these services call for;
- the optimal staffing patterns and levels (categories and numbers) in individual health facilities
according to local conditions (morbidity, access, attitudes) and not based on national averages
(population ratios and standard staffing schedules);
- the optimal staff categories and their activities, i.e. identifying where combining existing staff
categories or creating new categories will achieve maximum health impact with maximum
economy.
The WISN Method will produce all these types of results.
The pressing need now is to ensure that questions of the optimal allocation and deployment of staff
can be answered at two levels – at the national/provincial level, so that staff can be allocated or
distributed to districts equitably; and at district level, so that staff can be deployed to different
locations, services and facilities to best effect. In addition there are longer term strategic issues
4 __________________________________________________________________________________________
which must be tackled at the national level, concerned with volumes of training and determining
the optimal staff categories to employ in the health services.
In order to provide useful information to both medical and non-medical administrators at all levels
of the health service in these times of economic stringency and staff shortages, the new technique
should be:
- simple to operate, using data which is already collected and available;

- simple to use, so that the results can contribute to staffing decisions at all levels of the health
service;
- technically acceptable, so that health service managers are prepared to use the results in their
decisions;
- comprehensible, so that the results will be accepted by non-medical managers, e.g. finance,
planning, personnel administration;
- realistic, so that the results will offer practical targets for budgeting and resource allocation.
The WISN Method will meet all of these requirements.
2. The basis of the WISN Method

The WISN Method is based on the work which is actually undertaken by health staff. Every health
facility has its own pattern of workload which may include inpatients, surgical operations,
deliveries, outpatients, clinics of various types, health education, home visits, outreach activities,
inspection visits, etc. Each type of workload calls for effort (i.e. time) from specific health staff
categories. For example, a supervised home delivery requires the time of a midwife or trained
traditional birth attendant; a hospital outpatient may require time from a nurse (preparation and
recording), a doctor (examination), a laboratory technician (performing tests), a dispenser (filling
a prescription), and so on, depending on the medical practices and procedures which are followed
in the country. Sometimes treating a case requires time from several different staff categories
working together as a team, for example, in performing a surgical operation.
For each type of workload (inpatient, outpatient, MCH clinic, etc.) we can set an Activity
Standard. This is a unit time for each staff category - how much time on average a case, a
prescription, etc. should take each staff category which is involved in it, working to acceptable
professional standards. Alternatively we can set a standard rate - how many patients, laboratory
tests, etc. can be dealt with to an acceptable standard of performance per hour or per day. This unit
time or rate will differ, depending on the type of work (inpatients, outpatients, clinics, home visits,
etc.), on the category of staff dealing with the clients (on average ward nurses spend longer per day
with hospital inpatients than doctors do) and also on the type of facility (more complex cases are
referred to the higher level hospitals where on average they take more staff time per case).
This Activity Standard, an activity time or a rate of working (either can be used), can now be
converted into the equivalent annual workload, that is, how much of this type of work could be
done by one person in a year working to these professional standards and also making due
allowance for time spent on vacation, holidays, training, sickness absence, etc. This equivalent
annual workload is called the Standard Workload.
The amount of each type of work done in a health facility in a year is reported in its annual
statistics. Thus applying the Standard Workloads (annual work rates) to these annual statistics will
show how many staff in each category are required in order to accomplish this workload to
_________________________________________________________________________________________ 5
acceptable professional standards. This figure is the staffing requirement of the facility calculated
according to the WISN Method. The formula is:
Workload in the facility (service statistics)

= Staffing requirement
Standard workload (for one staff)
To be useful to decision-makers and managers, this figure of calculated staffing requirement must
be compared with the actual staffing level in the facility in order to identify where the shortages
and surpluses are, and how big, by staff category, in each health facility. Actual staffing figures
must therefore be available for the WISN calculations. Sometimes these staffing figures are not
compiled with the annual service statistics, and must be collected as a separate exercise.
3. Features of the WISN Method

The WISN Method takes account of the different type or complexity of care offered in different
facilities. For example, the treatment of an inpatient in a teaching hospital is usually more complex
and time-consuming than it is in a district hospital or a health centre. For this reason the ward
nurse spends longer in total each day with a patient in a teaching hospital than the nurse in a district
hospital does. This is reflected in the different unit times or rates set for inpatient care in these
different facilities. By using these unit times or rates, the calculations will show, for example, that
more ward nurses are required in a teaching hospital for the same number of inpatients as compared
with a district hospital or health centre. Calculations always show that more doctors are required
in the higher level referral hospitals for the same reason – each patient takes more doctor time on
average. A similar result is obtained with clinic attendances in teaching hospitals as compared
with, say, district hospitals.
However, where one particular activity is performed in the same way in all health facilities, e.g.
immunizations, then the same Activity Standard, i.e. the same unit time or rate (and its annual
equivalent the Standard Workload), is used for this activity in all facilities.
Thus a number of different Activity Standards may be used for one activity for technical reasons,
for example, to allow for more complex cases being treated in some health facilities. However,
no adjustment in Activity Standards is made because of location. In the calculations the same
Activity Standard for each activity is applied to all facilities of the same type, for example, health
centres, throughout the country. This means that the calculated staff requirements in each type of
facility are based on the same medical standards throughout the country. This is the basis of the
calculated equitable distribution of staff; it is the staff distribution which will offer the same
standard of service in health facilities of the same type.
The method can be applied to health facilities and services run by voluntary agencies, commercial
organizations, private practitioners, etc. provided only that their annual service statistics and their
actual staffing levels are available for the calculations. The results can be used to compare on a
consistent basis the relative staffing levels in government facilities and all these other facilities.
The method can be used by managers and staff in charge in individual facilities (health posts,
health centres, hospitals, etc.) if this is preferred. These results will show how the current levels
of each staff category employed in the facility compare to the staffing levels which should be
employed according to the national Activity (professional) Standards in order to cover the annual
workload in the facility. For this use, where managers and staff in charge apply the method
themselves, only simple calculations would be possible, and these can be set out on a pro forma;
an example used for nursing staff in health centres in Papua New Guinea is shown in Fig.1. The
6 __________________________________________________________________________________________
pro forma specifies what figures must be entered on the sheet (the workloads and current staffing
levels) and lays out the calculations (involving only simple arithmetic) in such a way that they can
be accomplished by clerical staff with very little training. Alternatively these simple calculations
can be done by the staff at district level, where the service statistics for individual facilities are
held.
On the other hand, the calculations are particularly appropriate for computers in the sense that they
can be set up (programmed) on such machines by computer operators (rather than the more
sophisticated computer programmers) using the standard facilities provided in widely available
computer packages (spreadsheets or databases). Thus the WISN calculations could be performed
on a central computer which can be programmed to produce the results for each health facility,
together with district, regional and national summary tables. This centralized approach is certainly
best where annual statistics for individual facilities are already sent to and held at the centre, and
its advantages may make it worthwhile to have these annual statistics sent to the centre where this
is not already done. In larger countries these calculations could be carried out at regional level,
with the results sent on to the centre for consolidation into national tables.
The method uses whatever service statistics are currently available rather than calling for special
data-collection systems to be set up, which is usually both time-consuming and expensive. Thus
using the WISN Method will extract extra information from the statistics which are already
collected at present and so offers an increased benefit from the current expenditure of resources
in collecting these regular statistics. The method is flexible in that it can take advantage of any
later improvement in these statistics, for example, wider coverage or greater detail, and thereby
produce more comprehensive or detailed WISN results. It can also highlight where changes in the
statistics would have the greatest effect in improving the quality of the WISN information
provided.
_________________________________________________________________________________________ 7
Figure 1 – Pro forma used for nursing staff in health centres in Papua New Guinea
Note: Use annual figures for the most recent complete year (Jan-Dec)
Province: Southern Highlands HC Nipa Year: 1986
District: Nipa
Recommended Recommended
Workload Calculation Workload Calculation
nursing officers CHWs
Admissions Admissions
/
1 291 / 600 = 2.15 1 291 300 = 4.30
Outpatients** Admissions
18 014 / 11 000 = 1.64 18 014 / 6 500 = 2.77
Total clinic
Attendances*** Admissions
20 764 / 700 = 2.97 20 764 / 9 000 = 2.31
Supervised births
275 / 150 = 1.83 Total 9.38
Total 8.59
Nursing officers ACTUAL

7 / Total 8.59 = ISN 0.81
Community health workers ACTUAL

11 / Total 9.38 = ISN 1.17
* CHWs = Community health workers including nurse aides, aid-post orderlies and orderlies working
in the centre.
** Outpatients do not include clinic attendances.
*** Total clinic attendances = new attendances and reattendances at antenatal, family-planning and child
health clinics.
Some essential work activities never appear in the annual statistics, for example, record keeping,
administration, supervision, staff management, etc. Full allowance for the workload caused by
these activities is made in the calculations.
8 __________________________________________________________________________________________
This approach is perfectly general and can be used for all health staff. However there is an easier
and better way of calculating the requirements of hospital ward staff (mainly nurses). It is not easy
to add up the durations of all individual contacts between nurse and inpatient to give the average
amount of time a nurse (or other category of ward staff) should give to each inpatient during a 24-
hour period. Rather the nurses are asked to specify the number of inpatients (occupied beds) for
which a nurse on duty should be responsible, e.g. one registered nurse per 16 occupied beds, one
nurse aide per eight occupied beds. These figures can vary according to the shift (morning,
afternoon, night) and the type of ward (medical, paediatric, etc.) One major advantage of this
approach is that it is much easier for nurses to estimate how many inpatients they can cover
adequately when they are on duty than it is for them to add up the total average time which should
be spent with each patient totalled over three shifts during a 24-hour period. And the results are
found to be more accurate as well.
The general WISN Method as applied to nurses (setting Activity Standards in terms of contact time
rather than inpatients covered) is based on a similar principle to the many methods currently used
for calculating immediate nurse staffing requirements for a particular ward. These methods divide
the inpatients into a number of dependency levels and specify the nursing effort (time) required by
inpatients at each level, usually derived from work study observations. These are more detailed
and sophisticated calculations which require detailed statistics (numbers of inpatients at each
dependency level) and produce detailed results, e.g. how many nurses of each type are required in
Ward 4 tomorrow morning?
The general WISN Method can also be applied to non-medical staff, e.g. administration, office staff
and support staff (laundry, kitchens, cleaners, drivers, etc.) Some of these calculations are based
on the service statistics, for example, for laundry and kitchen staff, but the remainder are based on
other data, e.g. the number of cleaning staff depends on the size of the facility, the number of
personnel administration staff depends on the number of staff employed, and so on.
In using annual statistics, the method calculates the average staffing levels required throughout the
year in order to cope with the recorded workload, even though the work is frequently seasonal with
higher workloads in some months than in others. In doing this the method corresponds to the
practicalities of the situation in that the staff employed in a facility are expected to cope with the
workloads as they arise, in the heavy months as well as the light. There is no regular procedure
for posting extra staff to facilities in their busier months. However, it would be possible to extend
the WISN Method to calculate what the seasonal staffing levels should be at different times of the
year, if ever these results should have a practical use for managers and administrators.
The practical use of the method by operational managers also requires figures for current staffing
in each of the health facilities covered by the WISN calculations. Sometimes these figures are not
readily available at the centre and a special data collection exercise must be undertaken to obtain
them from the district offices.
The WISN Method is based on setting unit times or rates of working for the different activities
which are undertaken by different staff categories. These unit times or rates are in effect quality
standards. Specifying 15 minutes per antenatal examination by a doctor, or specifying one
registered nurse on duty during the afternoon shift per 12 occupied beds in a hospital ward, implies
certain standards of health care quality and therefore certain codes of professional practice and
standards of professional performance.
There can be a significant practical advantage in addressing the question of what unit times or rates
(Activity Standards) to use for each staff category employed in the health service. The nursing
cadre frequently has a written code of professional practice, that is, Activity Standards, which can
_________________________________________________________________________________________ 9
be translated into Standard (Annual) Workloads for each nursing category. On the other hand,
many other cadres have no similar document, and setting Activity Standards for staff categories
within these cadres (for the purpose of the WISN Method) can be made the first step in setting
explicit national standards for staff performance and also producing written codes of professional
practice for these other cadres.
Sometimes the national standards of performance and professional practice which are officially set
in a country are much higher than current practice and would therefore require staffing levels in
health facilities which are very much higher than the current numbers employed. While these high
standards of health care quality are very desirable, it may in practice be impossible within the next
few years for the country to achieve them, that is, to recruit, train and pay sufficient staff to achieve
them. They could be considered as longer-term staffing and health care quality targets. The WISN
Method can assist in the planning to achieve these longer-term targets (see point 7 below).
However, the results produced by the WISN Method are also intended for immediate use by
managers and administrators in order to improve the current operation of health services. The
Activity Standards which are set for staff in a WISN exercise (and hence their Standard
Workloads) should not be too far from the current average conditions in the country. Otherwise,
the results (the calculated health workforce requirements) will be too high to be considered as
realistic staffing targets for individual facilities, districts, provinces and the country as a whole.
Such exaggerated results will not be of practical use in dealing with current problems and so will
not get any serious consideration from managers and administrators, who are mainly concerned to
improve the current situation. Activity Standards which are set only somewhat higher than the
current average professional practice in the country could be used to calculate interim or temporary
staffing targets; these figures would correspond to an improved standard of performance and
professional practice which could be achieved in the medium-term future in the light of the current
circumstances of the country.
If the standards of performance and professional practice are set too high by comparison with the
current situation, they produce figures for staffing requirements which are far too high to be useful
to managers and administrators. However, the method also produces from the same data
comparative figures of workload pressures, for instance, which facilities are under the greatest
pressure and therefore most in need of support; these results remain valid however realistic or
otherwise the standards of performance and practice used in the calculations may be.
It should be noted that the WISN Method calculates the staffing levels required to provide health
services according to certain professional standards in the country. If a facility has these staffing
levels, it does not necessarily mean that the staff there are working to these standards – that is a
matter for the supervisors concerned. Rather, what the calculation says is that in this situation there
are sufficient staff resources in the facility to provide the volume of health services which are
shown in its annual statistics according to the professional standards laid down for these services.
The method can also be used as part of the annual budgeting process. The salary and staff
establishment component of budget submissions can be compared with the corresponding
calculations of staffing requirements, for instance, the number of staff required to deliver existing
services to acceptable professional standards, in order to evaluate and/or justify existing posts as
well as any requests for new ones. If required, this calculation can be done for individual staff
categories and for individual health facilities.
10 _________________________________________________________________________________________
4. How the WISN Method works: differences and ratios

From the actual staffing level in a particular facility and its calculated staffing requirement
according to the WISN Method, two separate figures are calculated.
The difference, i.e. actual - calculated.
This shows the level of shortage or surplus. For example, if the actual number of nurses in a
facility is six and the calculated requirement to meet the current volume of work according to the
Standard Workload is eight, then there is a shortage of two nurses in the facility to meet acceptable
professional standards of service delivery. The six nurses in post are working under some pressure
to cope with the nursing workload in the facility, which is actually enough for eight nurses. Or if
the actual number of midwives in a facility is 10 and the calculated staffing requirement according
to the Standard Workload is eight, then the facility employs two midwives more than it requires
in order to meet its midwifery workload to acceptable professional standards. (This is not to say
that two midwives are idle in the facility, but rather that the facility can deliver a higher quality of
service, for instance, more midwifery services and care to patients, than other facilities which do
not have such a surplus.)
There is a very important point here. When we use the WISN Method to calculate staffing
requirements, these figures are not based on some theoretical need for staff according to the health
status or morbidity statistics in the population, or according to desirable staffing patterns in health
facilities. With these more theoretical methods, a calculated staff shortage (e.g. less staff in post
than the standard staffing pattern calls for), says nothing at all about the work pressures in the
facility. But staff requirements calculated by the WISN Method are based on the work which is
actually being done in the health facilities, for instance, the number of patients who are actually
being treated and the number of clients who are actually being served in the facilities. In these
cases a calculated shortage of staff in a facility actually does mean pressure of work on those
employed in the facility, which almost invariably leads to a reduction in professional standards. A
figure measuring this pressure of work is given by the ratio.
The ratio, i.e. actual/calculated.
This ratio is called the Workload Indicator of Staffing Need (WISN) and gives its name to the
method as a whole.
If the WISN ratio is 1.00, i.e. actual staff = calculated staffing requirement, then the current staff
is just sufficient to meet the workload according to the professional standards which have been set.
If the WISN is less than 1.00, then the current staff is not sufficient to meet these standards.
Continuing with the example above, if a facility has six nurses but is calculated to need eight, then
the WISN for this category is 6/8 = 0.75 or 75%, and only 75% of the required staff are available
or only 75% of the standards can be achieved.
If the WISN is greater than 1.00, then there are more than enough staff to meet the standards set.
For example, the facility mentioned above has 10 midwives but is calculated to need only eight;
the WISN for this category is 10/8 = 1.25 or 125%, and there is an excess of 25% in the midwives
above the number needed to achieve the standards set.
The WISN ratio is one of the novel features of this method. It shows the degree of pressure which
each staff category is under in coping with the annual workload it is actually dealing with in the
facility.
_________________________________________________________________________________________ 11
5. Using the WISN Method: identifying priority situations

The two figures – the difference and the ratio (WISN) – are used in combination and each has its
own function.
The difference between the two figures shows how big the imbalance (shortage or excess) is, and
where it is. It shows which facilities have a shortage in a particular staff category and which
facilities have an excess (as compared with calculated requirements) in the same staff category.
It is used for planning where any new staff should be posted and also for determining how staff can
be redeployed between facilities (to the extent that this is possible), in both cases with the aim of
achieving a more equitable distribution of staff and overall a more cost-effective service.
The ratio (WISN) shows where the workload pressure is the greatest and where it is the least, and
so where it is most urgent to take action in order to adjust staffing levels. It is used for identifying
which facilities should have priority when considering staffing changes (both increases or
reductions).
For example, compare the following two situations:
- a shortage of three nurses in a health centre where there are seven nurses but there should be
10 to cope with the workload. WISN = 7/10 = 0.7, i.e. 70% of staff requirements available,
30% understaffed;
- a shortage of 10 nurses in a hospital where there are 90 nurses but there should be 100 to cope
with the workload. WISN = 90/100 = 0.9, 90% of staff requirements available, 10%
understaffed.
The nurses in the health centre are under much greater work pressure (30% understaffed) and
therefore merit more urgent attention than the nurses in the hospital (10% understaffed).
Unfortunately the larger shortage (of 10 nurses in the hospital) would usually command attention
over the smaller shortage (of three nurses in the health centre), particularly when the larger figure
is backed by the authority of the hospital director or matron. These calculations offer an objective
method of prioritising situations of staff shortage, that is, identifying where the need is greatest and
so offering assistance in making decisions on staff deployment, for example, where best to post
new staff.
The same calculations can also be used to prioritise situations of staffing excess as well, that is,
identifying those places where staff can most easily be spared. For example, consider the
following two situations:
- an excess of four nurses in a health centre where there are 12 nurses employed but the
calculations show that only eight are needed to cope with the workload. WISN = 12/8 = 1.5,
i.e. 150% of staff requirements available, or 50% excess;
- an excess of 20 nurses in a hospital where there are 120 nurses employed but the calculations
show that only 100 are needed to cope with the workload. WISN = 120/100 = 1.2, i.e. 120%
of staff requirements available, or 20% excess.
In most instances the manager or administrator concerned would consider reducing the number of
nurses in the hospital ("They have well over 100 nurses, they will not notice a reduction so
much ...”) rather than in the health centre. However, the four extra nurses in the health centre give
a much greater degree of overstaffing (50% excess) and therefore some of these staff should be
12 _________________________________________________________________________________________
considered for transfer before reducing the 20 extra nurses in the hospital (20% excess). If the
health centre gave up two nurses and reduced its staffing to 10, then:
Actual staff = 10
Calculated requirement = 8
WISN = 10/8 = 1.25, i.e. 125% of staffing requirements available, or
25% excess.
This reduction of two nurses would bring the excess of the health centre nurses (25%) to be
roughly the same as the excess of the hospital nurses (20%). Thus if any nurses are to be moved
in order to relieve shortages elsewhere then, from the viewpoint of equity, moving two nurses from
the health centre should be considered before moving any nurses from the much larger number in
the hospital.
These examples show how the combination of difference and ratio (WISN) offers an objective
basis for making what are always difficult decisions of staff allocation, deployment, posting and
transfer.
These examples also show that the method can be used to compare directly the staffing situations
and workload pressures in different types of health facility (e.g. nurses in a health centre and in a
hospital), even where the staff category concerned may be engaged in different activities in these
facilities.
6. Using the WISN Method: improving the current staffing situation

The examples above show how the difference between the actual staffing levels and the calculated
staffing requirements in one health facility denotes the shortage or excess of staff in the facility
according to the actual workloads and the professional standards laid down in the country. The
ratio between actual and calculated staffing levels (WISN) shows whether these staff are working
under pressure in coping with these workloads and how much pressure there is on them, that is, to
what extent the professional standards can be upheld in the facility.
For example, in one country employing the WISN Method two categories of nurse (nursing officers
and nursing aides) are employed in health centres. Nursing officers deal with inpatients,
outpatients, clinic attendances and deliveries; nursing aides deal with inpatients and outpatients
only. In one health centre the results of WISN calculations for one year were as shown in Table 1.
Table 1 – Results for nursing staff in one health centre

Actual staff Required staff WISN ratio Difference
Nursing officers 6 8 0.75 -2
Nursing aides 10 8 1.25 +2
From these results the health centre manager concluded:
a) the shortage of two nursing officers balances the excess of two nursing aides; the total nurse
staffing of the health centre is correct but it is incorrectly allocated between the categories
according to their tasks (job descriptions);
_________________________________________________________________________________________ 13
b) it is likely that wherever possible some of the tasks of the overburdened nursing officers in
relation to inpatients and outpatients are being undertaken by the nursing aides (with an
excess of staff), who also attend these patients.
Similar calculations can be done for all staff categories in each health facility in a district, a
province and the country as a whole.
By comparing the calculation results (ratios and differences) for a group of such facilities, a
manager can identify whether there are any staffing inequities between the facilities and, moreover,
what can be done to improve the situation. In particular, the manager can determine:
a) which staff categories in which facilities are under pressure, how much pressure they are
under, and how big the staffing deficit is at each facility;
b) which facilities have staff in excess of their workload requirements, and how big the excess
is at eachfacility;
c) what staff movements (transfers) would bring about a more equitable distribution of staff
in the group of facilities;
d) which facilities should be considered first in these possible staff movements;
e) how many extra staff are required to bring the total staffing in the group of facilities up to
the level which corresponds to acceptable professional standards;
f) where any new staff should be posted in order to achieve maximum impact on the quality
of services provided.
A further example from the same country shows a summary of the results for nursing staff in four
health centres in the same district. These include those given above in Table 1, which are shown
as health centre A in the following Table.
Table 2 – Example of a district summary

Nursing officers Nursing aides
Health Actual staff Staff reqd. WISN ratio Short/ Actual Staff reqd WISN ratio Short/
centre surpl. staff surpl.
A 6 8 0.75 -2 10 8 1.25 +2
B 4 4 1.00 0 6 7 0.86 -1
C 7 7 1.14 +1 8 11 0.73 -3
D 9 9 1.22 +2 15 18 0.83 -3
District 29 28 1.04 +1 39 44 0.89 -5

totals
14 _________________________________________________________________________________________
From these figures the district medical officer concluded:
a) the district has about the correct number of nursing officers in its health centres, but they are
not optimally distributed. It would be very desirable, if it were possible, to transfer two
nursing officers from health centres C and/or D to health centre A;
b) the district has a net shortage of five nursing aides in its health centres, but even so the
situation could be improved by transferring up to two of these staff from health centre A.
The highest priority for employing extra nursing aides is at health centre C; although both
C and D are three nursing aides short, those in C are under the greater pressure (only 73%
of nursing aides in post) as compared with D (83% of nursing aides in post). In fact the
pressure on nursing aides in D (83% staffing, three short) is about the same as in B (86%
staffing, although only one short), because B is much smaller.
The results show:
- how the workload pressure in each facility can be compared with the average of the group;
- where the staff shortages or workload pressures are greatest for the different staff categories;
and therefore
- where new staff in each category should best be posted or where staff transfers would improve
the overall situation.
In other words, these results are used to identify staffing inequities between facilities and moreover
they can also be used to determine what specific actions can be taken in order to achieve equity in
the situation.
This will work even if there is an overall staff shortage in a group of facilities. For example, the
most equitable distribution of the 39 nursing aides shown in Table 2 can be calculated using the
WISN Method. The results are shown in Table 3, which sets out the actual situation (repeated from
Table 2) and also the calculated equitable distribution of these staff among the four facilities.
Table 3 – Equitable distribution of nursing aides

Actual situation Equitable distribution
Health Actual staff Staff reqd. WISN ratio Short/ Equit Staff reqd Equit Staff
centre surpl. staff WISN movements
A 10 8 1.25 +2 7 8 0.83 -3
B 6 7 0.86 -1 6 7 0.86 0
C 8 11 0.73 -3 10 11 0.91 +2
D 15 18 0.83 -3 16 18 0.89 +1
District 39 44 0.89 -5 39 44 0.89

totals
The calculated staff requirements in the four facilities remain the same, since this is based on the
workloads at each of them. The ratio between the calculated equitable staffing and the calculated
staffing requirement (called the Equitable WISN) lies between 0.83 and 0.91 for the different
facilities; this is the most equitable distribution of these staff that can be achieved in this situation.
The final column of the Table shows that it can be achieved by transferring three staff from health
_________________________________________________________________________________________ 15
centre A, two of these to health centre C and one to health centre D. The calculation shows what
is the most equitable distribution of the available staff which would enable all facilities in a group
to work under an equal degree of pressure.
The same approach can be used to review the workload pressures and the corresponding staffing
levels within a large facility, for example, the allocation of nurses to wards or departments in a
large hospital. This would identify instances of over- and under-staffing and determine what would
be an equitable distribution of staff. This is worthwhile only where there are large staff categories
in a health facility.
These calculations can be extended to compare staffing levels and workload pressures in several
different types of health facility in a district, for example, health posts, health centres, hospitals,
MCH clinics, etc. The results will show:
a) which staff categories in all these facilities are under the greatest pressure and therefore are
most in need of support;
b) what transfers of staff within the district would give a more equitable distribution of staff
between the facilities and a greater health impact if the same staff category is employed in
several different types of facility.
Some shortage categories are employed in only one facility, for example, X-ray staff or laboratory
staff may be employed only in the district hospital, and no transfers within the district are possible.
The calculations show which of these staff categories is under the most severe work pressure and
therefore which requests for extra staff should be pushed the hardest. The calculations also supply
a mathematical justification for such requests.
Another powerful feature of the method is that the results for each staff category can be aggregated
at different levels of the health service to produce the total in post, total calculated requirement,
total shortage/excess and average WISN (workload pressure). Thus the results can be produced
for each health centre in a district, together with the district totals and average, as shown in
Table 2. Then these district totals and averages can be listed for each of the districts in a region,
together with the regional totals and averages. Finally these regional totals and averages can be
listed for each of the regions in the country, together with the national totals and averages. Such
aggregated results can also be produced for each type of health facility (health posts, hospitals,
MCH clinics, etc.) or each category of staff (doctors, nurses, pharmacy staff, etc.) throughout the
country. Additionally, the results for all types of health facility in a district can be combined to
produce a comprehensive picture of the health staffing in a district, for instance, the total in post,
total calculated requirement, total shortage/excess and average WISN (workload pressure). These
figures can also be aggregated to produce similar comprehensive pictures of the health staffing for
each region and for the country as a whole.
Such aggregations are very powerful tools for human resource management in a district, a region
or in the country as a whole. However, such aggregations can give really accurate results only if
the figures are comprehensive, that is, they cover all the relevant health facilities which should
contribute to the tables. If an aggregation is based on statistics from only a proportion of the health
facilities which should be covered, then the results can give useful information on WISN ratios
(workload pressures) in the country, depending on how representative are the health facilities
which are covered by the figures. However, such calculations can give only an estimate of the real
staffing requirements (by correcting for the missing facilities), and hence only an estimate of the
real recruitment rates and training volumes which would meet these requirements. Of course, if
16 _________________________________________________________________________________________
nearly all the health facilities return their statistics then this estimate will be fairly accurate and
certainly sufficient to offer the basis of realistic recruitment and training plans.
An important aspect of these aggregated figures at all levels is that they take account of how the
local conditions (population, morbidity, access, attitudes, etc.) differ at each separate facility
covered in the calculations and how these variations affect the demand for services in different
facilities. For example, where these local conditions lead to a low demand for services, the
calculated staffing requirement by the WISN Method will be correspondingly low.
These WISN results can be used as the basis for allocating staff from the centre to regions, from
regions to districts, and to individual facilities within districts. In addition these figures are used
to guide future recruitment and training plans.
The calculations may show that there is a widespread and major imbalance between two related
staff categories, e.g. a shortage of qualified nurses and a surplus of nursing assistants. This
frequently signals that the surplus category may well be undertaking some of the activities of the
shortage category, e.g. nursing assistants performing injections instead of nurses. This shift of
activity occurs because of the pressures in health facilities from patients who are waiting for this
treatment. If such a shortage is expected to persist, it may be prudent to consider changes in the
training of staff (in the example, training nurse assistants to give injections). This can also work
in the reverse direction, for example, nurses performing essential cleaning or bed-making activities
in hospitals where there are persistent shortages of nursing assistants. Here the results show the
extent to which there is an inefficient and uneconomic use of highly trained professional staff.
Poor service quality and cost-effectiveness

In some situations the WISN results show that staff are under extreme workload pressure
(calculated staff requirement much larger than current staffing, WISN ratio small). This may arise
because the number of established posts in the facility is too small, or because most of the
established posts are vacant or, in some countries, because most of the staff are on secondment
elsewhere. These results mean that because of the workload pressures the staff are spending much
less time on average on each activity (e.g. patient consultation) than is set by the Activity Standards
and this indicates that the quality of the service being delivered is very much poorer than the
quality of service (acceptable professional standards in the circumstances of the country) on which
the Activity Standards are based. This is the situation, for example, in a health centre with one
doctor where the staffing requirement according to the workload is calculated to be four doctors
(WISN ratio 0.25). If the Activity Standard for outpatient attendances in this facility is eight
minutes, these results mean that the doctor spends on average only two minutes with each
outpatient.
In these days of cost-effectiveness and value for money, countries may wish to establish some
minimum average times for certain activities on the argument that with shorter times the service
is too ineffective and not worth the money it is costing. This would be equivalent to setting a
minimum WISN ratio, which may differ depending on the staff category and type of health facility.
If there is a health facility where there are WISN ratios less than this minimum level for a category
of staff and where there is no prospect of posting more of these staff, its situation should be
examined as a matter of priority. In some facilities there may be a compensating excess of staff in
a related staff category who undertake extra tasks (not in their job description) in order to equalise
the workload between staff categories. If a severe staff shortage in one category and loss of its
service quality occurs more generally in the country, it is a signal to consider alternatives, for
example, restricting the shortage category to perform only their more highly skilled tasks and
_________________________________________________________________________________________ 17
transferring their remaining tasks to another category in more plentiful supply; or allowing vacant
posts which are established for the shortage category to be occupied temporarily by staff in another
category; or changing the designation of some established posts which are continually vacant in
the facility in order to open them to another staff category in more plentiful supply; etc. All of
these would require professional, administrative, financial and perhaps union approval.
7. Using the WISN Method: human resource management and planning

The first use of the WISN Method in a country is usually to review the current staffing levels in
relation to the current workloads in health facilities using current medical procedures to current
professional standards, as described above. However, once the method is established, a whole
range of further uses are then available to assist in planning health services and to help solve
specific management problems as they arise.
The first calculations are based on current workloads, i.e. actual demand for health services.
a) By inserting in the calculations the anticipated workloads of planned future services e.g.
resulting from a planned increase in Primary Health Care services, the method will show the
staffing requirements in each category corresponding to future planned increases or other
changes in health services.
b) By inserting in the calculations what health services will meet the health needs (rather than
the demand for services) of the population, the method will show what the ideal health
staffing in the country should be.
The first calculations are based on the current professional standards set for each staff category.
a) Comparing the current staffing levels with the current workloads will show what is the
current professional performance, i.e. to what extent these desired professional standards
can now be met by each staff category, and which categories are most in need of support in
order to achieve them.
b) By inserting in the calculations new workload standards corresponding to improved

professional standards for some categories, the method will show how many extra staff
would be required in these categories in order to achieve the improved standards.
The first calculations are based on current conditions of employment, i.e. working hours, annual
vacation, sickness and other absence, etc., and also off-the-job training time required by current
in-service training policies.
a) By inserting in the calculations the figures corresponding to changed conditions of

employment for some categories, i.e. a shorter working week, increased vacation, etc., the
method will show how many extra staff would be required in these categories in order to
maintain services if these changes were introduced or to what extent services would be
expected to deteriorate if no extra staff were made available.
b) By inserting in the calculations the off-the-job training time required by new in-service
training policies, the method will show how many extra staff would be required in these
categories in order to maintain services with these changes or to what extent services would
be expected to deteriorate if no extra staff were made available.
18 _________________________________________________________________________________________
The first calculations use unit times or rates which are based on staff following the current medical
practice using currently available equipment.
a) By inserting in the calculations the new unit times or rates corresponding to new medical
practices, the method will show what effect these changes would have on the requirement
for each staff category concerned, e.g. what staff savings or redeployment could be expected
from new medical procedures.
b) By inserting in the calculations the new unit times or rates corresponding to the use of new
medical equipment, the method will show what effect these changes would have on the
requirement for each staff category concerned.
The first calculations are based on the unit times or rates of the current staff categories undertaking
their currently prescribed functions. By reviewing the range of these functions for each category,
their workloads and the overlap between the work done by different staff categories, the results can
be used to identify:
a) where there is a major imbalance and it would be an advantage to transfer functions between
existing categories of staff;
b) how best to allocate new functions to existing or new categories of staff, if new services or
procedures are to be introduced;
c) whether it would be an advantage to rationalize, i.e. reduce the number of existing staff
categories, and also how many staff would be required in the remaining staff categories to
cover the same workload;
d) what would be the staffing (and therefore financial) consequences of creating a new staff
category to take over specified functions from existing staff categories.
8. The constraints and limitations of the Method

The WISN Method is a management tool for improving decisions at all levels of the health service
about the provision, allocation and deployment of staff. Its calculations and results are based on
the annual service statistics. These statistics in effect provide a summary picture of a facility's
workload over the whole year. These factors can impose a number of constraints and limitations
on the method and the results it produces, mainly related to the use of the annual service statistics.
Most of these constraints and limitations can be dealt with in the calculations.
In using annual statistics, the accuracy of the method is determined by the accuracy of the statistics
themselves. Where the initial record-keeping in a facility is poor, the results will be inaccurate,
almost invariably in the direction of under-recording workload and hence under-estimating the
staffing requirements of the facility. However, if the WISN Method comes into general use and
managers, staff in charge, etc. come to realize that their staffing allocations are based on their
annual service statistics, the record keeping will improve and the errors may even move in the
opposite direction of ove-recording.
Annual statistics are usually produced by aggregating monthly returns and it is not uncommon for
some monthly returns to be missing from the records at the end of the year. This particular
_________________________________________________________________________________________ 19
situation is not a problem. The method automatically allows for incomplete records and bases the
calculation on the monthly returns which are available.
In using annual statistics, the detail which can be achieved in the initial results of the calculations
is determined by the detail which is available in the statistics themselves. Initial calculations of
the requirements for a staff category are based on statistics of the activities (workload) of these
staff. If two similar staff categories undertake the same activities (or if the different activities they
undertake are combined and reported as a single figure in the annual statistics) then calculating the
separate requirements for each category is not immediately possible. In these cases, calculations
based on this single figure would produce a single figure showing the combined requirement for
the two staff categories. A further step in the calculation is then necessary in order to produce the
requirements for each staff category separately. For example: in one country which has
implemented the method, two categories of nurses undertake the same activities in health posts.
Calculations based on the annual statistics for these activities show the combined requirement for
the two categories. The managers there have also decided that the activities undertaken by both
categories should be 60% by one of the staff categories and 40% by the other. A further step in
the calculation divides the combined requirement in the ratio 60:40, to produce a figure for the
requirement for each of the two staff categories separately.
The level of detail in the statistics can also affect the accuracy of the results. For example, where
the service statistics show a single figure for antenatal examinations, the Standard Workload is
based on an average unit time or rate for all antenatal examinations. However, the first
examination of an antenatal client should take longer than the subsequent visits. Where the
statistics show separate figures for first visits and subsequent visits, a different unit time or rate can
be used for each of these two figures to produce a more precise figure for the staffing requirement
for this activity of antenatal examinations. Exactly the same effect occurs in the treatment of
outpatients, with the first visit usually taking longer than subsequent visits. Again, some service
statistics show a single figure for all laboratory tests performed whereas others show the numbers
of haematology, bacteriology, parasitology, etc. tests separately. Using an appropriate unit time
or rate for each type of test in the calculations gives a more precise figure of the requirement for
laboratory staff as compared with using one overall average unit time or rate together with a total
figure for all laboratory tests. These more detailed calculations would also show directly the
requirement for staff working in haematology, bacteriology, parasitology, etc. in the laboratories,
where this specialization is warranted.
In using annual statistics, the method calculates retrospectively, what the staffing levels should
have been last year, when the statistics were collected. This is usually not a serious practical
problem since facility workloads change relatively slowly in step with catchment populations and
economic circumstances. If necessary a percentage correction can be made to the results to allow
for the annual trend in a facility's workload.
Sometimes lack of materials can reduce the workload in a facility. If such shortages are relatively
few and minor during the year, their effects can usually be ignored. But if the shortages are major
and long-lasting, then the recorded annual workload in the facility is determined not by the demand
for services in the locality but by the lack of materials. For example, if no X-ray films are available
in a hospital for much of the year, then the X-ray machines cannot operate and the recorded annual
number of X-rays taken in the hospital may reflect how much film was available rather than how
many patients needed X-rays. Similarly, if there is a longstanding shortage of drugs, the recorded
volume of workload in the dispensary (e.g. number of prescriptions filled) may reflect more the
drug supply situation than the number of patients who were given prescriptions and should have
been served. In both cases the results of the ordinary WISN calculations will show the number of
20 _________________________________________________________________________________________
staff required which corresponds to the low workload figures, that is, the staff which would be
required while such shortages continue.
Of course, when supplies increase the recorded workload will also increase and the WISN
calculations will show how many staff are required in the new situation. However, it may be
unacceptable to wait for a whole year before calculating the new staffing requirements
corresponding to an improved supply of materials. If it is known that supply shortages are
seriously limiting the volume of health services which are being delivered, so that the annual
statistics show figures lower than they would otherwise be, then special adjustments can be made
to the WISN calculation. For example, the workload figure used in the calculation can be an
estimate of what the volume of services should be (or is expected to be when the supply position
improves) rather than what it currently is.
_________________________________________________________________________________________ 21
22 _________________________________________________________________________________________
___________________________________________________________________________ Section B – Steps in design and implementation of the method
Section B:
Steps in design and implementation
of the method
This section covers the basic steps in implementation. It sets out the administrative arrangements
for designing and implementing the WISN Method in order to achieve two objectives: first, so that
the new procedure will function effectively; and second, so that its operation and results will be
integrated with the ongoing management and budgeting procedures. It describes the main activities
which must be undertaken during implementation and how these may be fitted together into an
overall workplan for the implementation exercise.
Contents
1. Starting the process: setting the objectives ...................................................................... 23
2. Choosing the basic design of the procedure to be implemented ...................................... 26
3. Setting up the implementation group ............................................................................... 28
4. Procedure for establishing standards of professional performance .................................. 31
5. Mobilizing commitment to the WISN Method................................................................. 32
6. Collecting and handling the data ...................................................................................... 32
7. Plan and budget for operating the new procedure in regular use ..................................... 34
8. Workplan and budget for implementation ........................................................................ 35
For convenience this Manual assumes that the Ministry of Health (MOH) or its equivalent in the
country, is commissioning the work to design and implement the WISN Method, and that it will
provide most of the resources (staff, materials, transport) in getting the new procedure up and
running. In countries where the initiative is being taken by another body (Regional or Provincial
Health Authority, health consortium, etc.), the name of this body should replace “Ministry of
Health” or “MOH” in what follows.
1. Starting the process: setting the objectives

The decision to implement the WISN Method and to set specific objectives for the new procedure
must be approved by the most senior staff in MOH for two reasons:
a) Use of the results: resource allocation decisions, particularly those concerning staff, are
taken at the highest levels of MOH and frequently involve strongly-held views and hard-
fought battles. A new technique which aims to provide an objective basis for making many
of these decisions must be approved by the staff at these senior levels. Otherwise, if its
results are unwelcome in these decision-making processes, it will not be used there and it
will not then command respect at lower levels. The method must secure top level support
and a public commitment to use its results if it is to operate effectively.
_________________________________________________________________________________________ 23
b) Coverage: the method can be applied to all facilities, services, staff, areas, etc. A decision
to exclude some parts of the health service from the calculations, and therefore from an
assessment of the service quality and equity of staff distribution in them, requires a top-level
decision.
Considering the novelty of both the WISN Method and the information it produces, these top level
decision-makers may require some background on the basis of the method, its operation, its results
and their uses before they can come to the initial decision on whether to approve the
implementation of the method. This background material will be found in Section A of this
Manual.
Once the decision to implement the method has been taken and backed by the most senior staff,
it is necessary to set specific objectives for the exercise. The objectives which are set at this stage
should include:
- the services and types of health facility which are to be covered by the WISN procedure;
- the geographical areas to be covered;
- the staff categories to be covered (which in the first instance should be health professionals, not
staff without health training);
- the use of the results - who will use them, and for what purposes.
The decision-makers may choose a phased implementation of the WISN Method and set initial
objectives which will cover only part of the total health service. This phased approach may be by
staff categories. Covering the largest cadres first gives the maximum pay-off for a given amount
of effort. For example, the initial implementation in Papua New Guinea covered nursing staff in
all rural health centres, urban clinics and hospitals and also aid post staff; these comprised 87% of
the total government health staff in the country. The method was later extended to other
paramedical staff (laboratory, X-ray, pharmacy, anaesthesia, physiotherapy, occupational therapy)
throughout the country and then to hospital-based doctors. It may be desirable to cover first those
staff categories which have priority staffing problems. In Kenya the method was applied first to
hospital technical staff where major mismatches between supply and demand were suspected
(radiographers, laboratory staff, pharmacy staff and physiotherapists) and the work was later
extended to hospital doctors, nurses, etc. In Sri Lanka the method was first applied to dental staff
because there was very strong support from the most senior level of the cadre and also detailed and
comprehensive dental service data was readily available. These results provided to senior staff in
other cadres a convincing demonstration of how the method works and its value.
Alternatively the phased approach can be geographical and/or by type of health facility. The
implementation work can start in a few localities, e.g. districts, and then expand in a number of
carefully planned phases to cover the whole country. For example, the initial implementation in
Tanzania covered all staff categories in the health centres and dispensaries in two districts (one
urban and one rural) in different regions. The method was later extended to all health centres and
dispensaries in the remaining districts in the two regions. Subsequently all hospital staff in the two
regions were covered. Finally the method was extended to all health facilities in the remaining
regions in the country.
A phased implementation which starts in a fairly small way with a few staff categories and/or
geographical area and/or types of facility has two main benefits. It allows the implementation
group (see point 3) to learn from direct experience how best to do their job. It also provides early
examples of in-country results which can be used to good effect when introducing the method
24 _________________________________________________________________________________________
subsequently to other locations, staff categories, types of facility, etc. in the later phases of the
work.
It is usually best to complete the implementation for MOH services before considering extending
it to other government health services (armed forces, prison health services, etc.) or to non-
government health services (provided by missions, companies, plantations, privately-owned health
facilities, etc.)
It is also important to consider how the results are intended to be used, and by whom, as part of the
objectives of the exercise. There are a number of possibilities here:
- the centre e.g.the Ministry of Health, and within that:

- service departments, e.g. curative services, PHC, etc., to monitor the allocation and deployment
of staff to different types of health facility and geographical areas, to identify particular
situations of staff shortage/excess, to determine how best to deploy each staff category in
relation to actual requirements;
- vertical programmes, e.g. malaria, to monitor the allocation and deployment of staff in relation
to workload in different geographical areas in the country, and to determine how best to deploy
staff in relation to actual requirements;
- personnel administration, to monitor the overall deployment of different staff categories in the
country, to have a rational basis for reviewing requests for staff increases and determining the
posting of new staff, to have a rational basis for reviewing requests for staff transfer and to
control the transfer of staff in accordance with actual service requirements, to have quantitative
estimates of the shortages in each staff category;
- finance, to secure a quantitative basis for the salary and other emoluments component of annual
budgets, to be able to provide figures for the service effects of proposed budget increases or
cuts;
- planning, to have estimates of the staffing requirements by category for planned services or
proposed changes to them;
- provincial and/or district health offices, and the service, personnel, finance and planning
functions at province and/or district level, particularly for countries with decentralised services.
The decision on the use of the results at these levels will depend on the responsibilities and
authority delegated to each of these levels. The WISN results can only be used in practice at
those levels which have the responsibility and authority for one or more of the following:
posting new staff, deployment of existing staff, transferring staff between facilities, setting
staffing targets, health workforce planning);
- large hospitals, for the allocation of staff to Departments and wards;
- ministry of local government (if local health services are part of local government services);
- ministry of education, if it is responsible for the teaching hospitals, school health services, etc.
and approves their budgets, deploys their staff, etc.;
- any other government ministry which has the responsibility for providing a significant amount
of health services and also controls the budget for these activities, e.g. the armed services, the
prison service, etc.;
- public services commission or its equivalent, to monitor the medical activities undertaken by
health staff categories and their workloads, consider the need for changes in the number and
scope of health staff categories;
_________________________________________________________________________________________ 25
- missions and other health NGOs, company/plantation health services and private health
organizations which employ substantial numbers of staff in order to provide health services to
the population at large, to employees, etc.
- medical and other professional bodies and trades unions for health staff.
This is an exhaustive list of those organizations, bodies and groups in a country which could find
the results of the WISN Method useful. It covers all the possibilities which usually arise. However,
only the most important of them should be included in the initial objectives. The purpose of the
list above is to offer a number of suggestions from which to choose those organizations, etc. which
should be selected as the first set of users of the results of the WISN Method.
2. Choosing the basic design of the procedure to be implemented

Once the objectives have been established it is necessary to consider one major aspect of the
procedure which will be used in the implementation – whether it will be manual or computerized.
This must be done before it is possible to determine the timetable and the resources required for
implementing the method.
The WISN procedure which is to be implemented is best considered as being divided into three
main activities:
1. Collecting the data to be used in the calculations.

2. Performing the calculations and producing the tables of results.
3. Using the results in management decisions.
When the procedure has been established as a regular component of the annual cycle of operations,
the first two activities are performed once a year, as soon as the new set of annual service statistics
are available. The third activity is continuous and always uses the most recent set of WISN results
available.
In deciding on the system to be implemented in the country, there is one major choice to make -
how and where the calculations are to be performed – and there are two principal options to
consider in making this choice.
One option is manual calculations, in which each health facility which is to be covered in the
exercise could carry out its own calculations to produce its own results for its own use. These
results are sent to the next higher level (e.g. district health office) to be consolidated with similar
results from other facilities to produce the aggregated tables of district results (totals, averages and
comparison of units) for use by the district health team. These district tables of results are then sent
to the next higher level (for example, provincial health office) for consolidation and use by the
provincial health team, and so on up to the MOH. This way of doing the calculations calls for the
design and printing of a set of pro formas (one for each staff category) for all the individual
facilities. At each facility the data items (annual service statistics and actual staffing) are entered
and the calculations (simple arithmetic only) are performed. An example of such a pro forma,
which was used in Papua New Guinea, is shown in Fig.1, Section A. (Whether this is a practicable
option depends on the calibre and educational level of the staff in charge of the health facilities
being covered in the exercise; in rural health facilities in some countries this option could not be
considered.) In addition, a separate set of pro formas must be designed and printed for each level
of aggregation of the results (district, province, MOH).
26 _________________________________________________________________________________________
An alternative here is for the manual calculations for each facility to be performed by the clerical
staff in the district health offices (where the annual service statistics and actual staffing levels for
each facility are usually available); the results for each facility are then sent to the facilities for
local use. These results for each facility are combined by the district health office staff to produce
aggregated tables of district results for use by the district health team. They are also sent to the
next higher level, as described above.
The other option is to use computer calculations in which the data (annual service statistics and
actual staffing for each facility) are sent to a centre (MOH if computers are available there) and the
results for each province, district and facility are printed out and sent back to them. It is
undoubtedly easier, cheaper and more reliable for computers to do the calculations and to print out
tables of results for each province, district and the individual facilities. By using computers it is
also relatively easy to do more complex and sophisticated calculations in order to extract more
useful information from the data. The main disadvantage of this choice is the large volume of data
input into the computer which must be done at the centre. If computers are available at province
or district levels, the data input and calculations can be done there (using standard computer
programmes supplied by the centre), with printed tables of results sent to the lower levels and
diskettes of data sent to the higher levels for aggregation. In Tanzania the data sheets for each
health facility were sent by the district health offices to MOH to be entered into a computer, and
the printed-out tables showing the results for each facility and district totals/averages were sent
back to each district.
In considering which of these two approaches to use, it is important to consider what must be
accomplished and what it costs in order to implement each of them.
Manual calculations
1. Pro formas for the calculations, one for each staff category employed, must be designed and
printed; different pro formas are needed for each type of facility (clinic, health centre,
hospital, etc.) and also for each level of the health service at which results will be produced
(facility, district, province, centre).
2. Instruction booklets on how to complete each of these pro formas (for each staff category,
for each type of facility, and for each level of the organization) must be written and tested.
3. A sufficient quantity of pro formas and booklets must be printed to supply all the facilities
and all the district and provincial offices covered by the exercise.
4. Training sessions will be necessary in each district to introduce the pro formas to those staff
who will fill them in and to go through the instruction booklet with these staff using worked
examples. For the implementation exercise the pro formas and booklets to be used in the
facilities can be distributed during this training. In subsequent years, when the same pro
formas will be used, no training is necessary so the pro formas will have to be distributed
to the facilities by a different method.
Computer calculations
1. The implementation exercise will need the services of an individual who is able to use
spreadsheets, in order to design and enter the data input format and the calculation formulae.
_________________________________________________________________________________________ 27
2. Both in the implementation exercise and also in subsequent years there will need to be access
to a computer with a spreadsheet programme (Lotus 1-2-3, Excel, etc.), and the method calls
for the purchase of a number of diskettes each year for data storage (one per district).
3. The annual service statistics and actual staffing levels of individual facilities must be made
available for input into the computer from the most convenient source. Sometimes these
statistics are already available at the centre and perhaps some of them may even have been
computerized. At worst they are available in the district health offices. It is rarely cost-
effective to arrange to collect them from individual facilities. If the annual statistics for
individual facilities are not compiled from their monthly figures in the district health offices
it may be necessary to design and send out a form to each district office on which the
monthly figures are copied from the files by the district health office staff and returned to
the centre. Normally completing these forms, which are then used as computer input sheets,
requires no special training.
4. The annual service statistics and actual staffing levels of each facility must be input into the
computer. This procedure is not difficult to perform, but it does require individuals who are
capable of focused attention and of maintaining their application to a task.
Although either computers or a purely manual method can be used, the computer-based system is
a good deal cheaper in running costs, significantly faster in operation and much more powerful and
reliable in doing the calculations. Also most MOHs have at least one computer with a spreadsheet
package on which the calculations can be done once a year. The remainder of this manual
describes the implementation of the WISN Method based on using a computer to perform the
calculations and to produce the tables of results. A manual method using specially designed pro
formas for the calculations follows exactly the same principles, although some of the practical
details of operation are different.
3. Setting up the implementation group

The implementation group is the name given to all those who are concerned with the design of the
new procedure and its implementation according to the objectives which have been agreed. The
implementation group consists of two sets of people:
- the steering committee, whose functions are to set the policies for the work within the agreed
objectives, to approve strategies for implementation, to agree workplans and budgets for the
development, to monitor progress, and to maintain an overall supervision of the work;
- the implementation manager and his/her task force, whose function is to do the job.
The steering committee

Normally the primary responsibility for designing and implementing the WISN Method in a
country is given to one MOH department or unit, e.g. planning department, health manpower
planning unit, personnel department, etc. A senior member of MOH whose responsibility includes
this department or unit should be the chairman of the steering committee. The implementation
manager should be a member of the department or unit which has been selected to carry out the
implementation.
The steering committee should consist of:
28 _________________________________________________________________________________________
- representatives of the providers of the information: representatives of the MOH functional

departments responsible for the type of health facilities and/or the Provinces and Districts in
which the initial implementation is to take place. Thus if the objectives specify that the rural
health services are to be covered in the first implementation, then a representative of the MOH
department responsible for these services should be a member of the steering committee. If
implementation is to start in one specific province or district or a number of them, the
corresponding provincial or district health officers should be members of the steering
committee. (If there are also central (MOH) Departments responsible for the health services
in geographical areas, then representatives of those departments which cover the areas of initial
implementation should also be members of the steering committee.)
- representatives of the users of the results: representatives of the organizations, bodies and
groups which are to be initial users of the results of the WISN Method, according to the
objectives which have been set for the initial implementation. This will very likely include
many who are also providers of information.
The chairman, responsible for the department or unit undertaking the implementation of the
method, is also responsible for the budget which is giving the major support to this work.
The implementation manager

The steering committee must appoint an implementation manager to be responsible overall to the
steering committee for the implementation of the WISN Method and also for its integration into
the management and budgeting procedures of the organization, that is, the institutionalisation of
the new procedure. The implementation manager will be a senior officer in the department or unit
selected to undertake the implementation exercise. The implementation manager must be a
sufficiently senior officer to have access to the senior decision-makers in the MOH, and also have
sufficient status to command respect from Provincial and/or district health officers, staff in other
government departments, representatives of the health professions, etc. The implementation
manager acts as the secretary of the steering committee.
The task force

The task force is led by the implementation manager and consists of:
- full time core staff, drawn largely from the implementation manager's own staff and located in
the task force office;
- full time or part time technical resource persons, e.g. a statistician, a computer operator, etc.,
usually seconded from another group to work in the task force office;
- liaison persons, undertaking some local activities as and when necessary, e.g. arranging
meetings, obtaining documents or information, etc., in the cooperating MOH departments and
the initial provinces/districts.
The task force usually starts with whatever staff and other resources the implementation manager
can mobilize by his/her own ingenuity and enterprise. The actual task force requirements become
clear when the workplan for the implementation exercise is produced.
_________________________________________________________________________________________ 29
Administrative locus of the WISN implementation activity

The steering committee and the task force are intended to be temporary groups which exist during
the implementation of the WISN Method for the sole purpose of achieving that implementation.
When this is completed, the WISN activity should be a regular annual procedure (like budget and
training school intakes) located in personnel or planning or some other appropriate department. For
example, if the health service statistics are computerised, the WISN results could be produced
automatically as a sub-programme of the annual statistics, and the WISN function could be part
of the health information system.
The manual recommends a steering committee function to oversee the exercise and a task force
(executive function) to carry out all the activities required (set Activity Standards, collect data, set
up computer spreadsheets, input data, produce results). Often these functions are performed by a
Steering Committee and Task Force set up for the purpose. But for convenience the WISN
exercise may be integrated into an ongoing programme of work, for example, producing a
personnel plan for one or more categories of health staff, reviewing the budgets and established
posts (staffing review) in some or all health facilities, planned reduction in the number of health
staff categories, etc.
There are both potential advantages and disadvantages in integrating the implementation of the
WISN Method into an ongoing (usually larger) programme of work.
Advantages: if the ongoing programme already has high-level backing within the ministry and a
substantial budget, the WISN task force has the use of this authority (access to senior staff at the
centre and in the provinces) and resources (office space, transport, photocopying, computers) in
order to undertake its activities without having to establish or procure them for itself.
Disadvantages: the aims of the ongoing programme will be at least wider and perhaps even
different from the aims of a WISN steering committee and task force. If a task force is appointed
from within the ongoing programme, the skills and capabilities (and also the interests) of the staff
may not be directly relevant to the tasks of WISN implementation. In addition, if one or more
existing working groups are given the extra responsibilities of a WISN task force, their focus on
the aims of the ongoing programme may delay, constrain or even negate progress on WISN
implementation.
Liaison between steering committee and task force

It is very desirable for the liaison between the steering committee and the task force to be
institutionalized. This is done in Egypt, where the leader of the task force is the secretary of the
steering committee, and in Oman, where the Director General of Planning is a member of the
steering committee and the Director of Planning is the leader of the task force.
30 _________________________________________________________________________________________
4. Procedure for establishing standards of professional performance

The workload standards to be used in the calculations are based on standards of adequate
professional performance and service delivery. If these professional standards (Activity Standards,
see A.3) are to be applied nationally and the results are to be useful, they must be realistic. It is of
course understandable that a country would like to have the best medical services for its
population. However, if Activity Standards for the exercise are set too high they will produce
calculated staffing requirements which are very large and quite beyond the country's capacity,
either to train them or to employ and pay them, in the near or medium term future. The Activity
Standards set in the exercise must be practicable in the circumstances of the country, that is, they
must be achievable in the medium-term future, if the results are to have any practical value as a
basis for current managerial decision-making. These practicable standards can be considered if
necessary as a set of intermediate targets. When these intermediate standards have been achieved,
higher professional standards can be set as new targets for achievement and the WISN calculations
are then repeated to produce new staffing requirements.
Furthermore, the standards which are set must be authoritative, that is, they must have the backing
of senior and respected individuals who can speak on behalf of a cadre. One way of achieving this
is for the standards for a cadre to be set by a group of selected senior staff in the cadre who have
a wide-ranging and long experience of the duties and working activities of the cadre, for example,
a group of nurses each in charge of several rural health facilities who themselves have worked in
a number of such facilities, a group of senior laboratory technologists in charge of the major
hospital laboratories in the country, a group of hospital matrons from different types of hospital
(district, provincial, national, teaching), a group of medical officers each with some years of
experience of working in different types of hospital in the country, a group of consultants and
professors from one specialty in the teaching hospitals (at this level each medical specialty must
be dealt with separately; similarly the specialist hospitals must be dealt with separately as well).
Each of these groups of staff is expected to bring to bear professional expertise ("how should things
be done?") and recent working experience and/or observation ("how much of this is practicable?")
concerning their cadre. Each such "cadre group" should include a representative of the relevant
department of MOH which deals with the cadre being considered.
An alternative approach which has been found successful, particularly for hospital staff, is to invite
the senior staff from all departments or units in a facility to work together to set the Activity
Standards for all the staff categories who work in their own and similar facilities. Thus all the
senior staff in a hospital could be invited to a workshop in which carefully selected working groups
draft the Activity Standards for all the cadres employed in the facility; these standards are then
discussed and approved in plenary session. Representatives of the relevant MOH departments
should also attend the workshop. In using such a "facility group" it is usual to select a hospital, etc.
which is generally reckoned to have a good performance in order to set Activity Standards. The
aim is to use the results of the workshop as the national standards for the staff employed in this
type of facility in the country.
The detailed instructions and guidance for producing Activity Standards are the same for both
approaches - cadre groups or facility groups. They are given in Section C.2. This procedure
establishes the Activity Standards which are to be used for all the staff categories which will be
covered in the implementation of the WISN Method. Setting the Activity Standards which are to
be used in the implementation exercise is a task which must be fitted into the early part of the
workplan for the implementation exercise.
_________________________________________________________________________________________ 31
Sometimes a cadre has already established its own standards of professional practice. For example,
in many countries the nursing cadre has produced a handbook of nursing standards (or practice)
which stipulates for each category of nurse the number of hospital inpatients which should be
supervised per ward nurse on duty (which may differ for different types of hospital and/or ward
and/or shift), the number of outpatients which can be treated per day, and the number of clinic
clients which can be seen per day (which may differ for different types of clinic). Normally some
items in these handbooks or standards of practice can be converted directly into Activity Standards
for use in the WISN Method. Also the health services research groups in some countries have
carried out job analyses or work study exercises on certain staff categories and can supply accurate
timings for various activities.
5. Mobilizing commitment to the WISN Method

There is one further activity which must be undertaken during the implementation exercise. If the
WISN Method is to succeed in the country, it will be necessary to mobilize the commitment of the
potential users of the WISN results which the method produces. Unless the results will be used to
improve the management and operation of health services in the country, the work should not be
undertaken. It should be emphasized that the WISN Method produces an entirely new type of
information (workload pressure) as well as detailed information not normally available (staff
shortage/surplus for each staff category in each health facility). Therefore managers at several
levels (national, province, district) must be trained in how to use the WISN results for their own
decision-making. This is best done in half-day or one-day workshops for groups of up to 20 at a
time, although larger groups have been used successfully. In these workshops the material in
Section A is presented, using examples and results from the country itself wherever possible. After
each segment of the presentation the participants split into working groups to review sample tables
of results and identify what management action they call for. These workshops should be
scheduled soon after the implementation exercise has begun so that some tables of results from the
country itself are available for demonstration and for working group exercises.
It can also be most desirable (depending on the circumstances of the country) for representatives
of the professional bodies (for doctors, nurses, dentists, etc.) and of any trade unions representing
health staff to be invited to these workshops as participants, so that they can understand what the
new method is and how the results are to be used.
6. Collecting and handling the data

Before starting to plan and budget for the implementation exercise, there are two major factors
which must be investigated and decided - how the most recent set of annual statistics from health
facilities are to be assembled for input into the computer, and what resources will be required for
computerizing this data and producing the results.
Collecting the data

Assess the possible sources of the data required (annual service statistics and actual staffing
numbers for each facility) and how the data can be obtained. This could require visiting a number
of district health offices to investigate:
a) the service statistics which are received from health facilities and stored: do all facilities
make statistical returns? are those which are received complete or are some items or even
some months missing? how promptly are they received? do the district health offices
32 _________________________________________________________________________________________
actually aggregate the annual statistics for each facility from the monthly figures? how
accurately is this done (e.g. are missing months ignored)?
b) data on the actual staffing in health facilities: is it complete? up-to-date?
c) the form in which the statistics are held: are summary sheets prepared which contain the
workload data required by the WISN Method? if so can these sheets be borrowed or
photocopied for computer input?
d) is there adequate administrative and clerical capacity in the district health offices to
undertake various activities, e.g. to assemble the statistics for each facility from the files, to
transcribe these statistics from the records to computer input sheets?
e) the practical scheduling of the activities in (d): are there other priority activities which will
occur in the district health offices during the planned period of the implementation exercise
and which would cause difficulty or delay?
f) what transport will be available for visits to district health offices and provincial health
offices to arrange for and/or undertake the collection of the data?
When the answers to all these questions have been assembled, it will be possible to make an
informed judgement on the best method of collecting the data for the WISN calculations, and also
to set out the reasons for justifying this judgement to the steering committee.
If all the data (service statistics and staffing for each facility) is already available at the centre, this
part of the investigation will be easier and less time-consuming.
Producing the results

Assess what resources will be required to computerize the data and to what extent these resources
are available:
a) Which computers might be used? How much spare capacity do they have? Would any
regular production jobs they may have clash with developing the WISN spreadsheets and
running the calculations? It might be possible to identify the computer which will be used
when the new WISN procedure is in regular operation but also it could be desirable to use
a different computer during the implementation, e.g. a computer used for research, where
access for setting up and testing the computer calculations may be easier.
b) Which staff with a knowledge of spreadsheets could be available to set up the WISN
calculations on the computer? Under what circumstances or arrangements can they be made
available for the task?
c) What arrangements must be made for the task force to supply its own materials (paper,
printer ribbons, etc.)?
Answers to the questions are necessary in order to decide on how to computerize the data and
justify these decisions to the steering committee.
_________________________________________________________________________________________ 33
7. Plan and budget for operating the new procedure in regular use
Before undertaking the detailed design and planning to set up the new procedure it is most
desirable to look briefly beyond the implementation activities and consider how the procedure will
operate in subsequent years when it is established as a regular component of the annual cycle of
operations in the health services. The results of this assessment could affect what is to be done
during the implementation exercise. The questions which should be addressed here are:
1. Who will be responsible for the effective operation of the procedure? Which unit will
perform the annual exercise of obtaining service statistics for each facility to be covered,
entering these service statistics into a computer, and printing out the tables of results? Which
unit will respond to particular enquiries and requests for calculations during the remainder
of the year? (These could be two different units.) Where will the unit(s) fit in the
organogram?
2. Will the procedure require employing extra staff? (This is most unlikely since it occurs only
once a year soon after the beginning of the financial year, when the annual service statistics
for the previous year become available.) What staff will be used in operating the new
procedure? What will their respective tasks be? What changes will be required to existing
job descriptions?
3. What will be the annual direct costs of operating the procedure, e.g. obtaining computer
diskettes to store district data, etc.? On whose budget will these costs appear?
4. Which computer will be used? (The computer will be used fairly intensively for these
calculations for a few weeks each year when the new set of annual service statistics becomes
available.)
5. How is the data to be collected each year? Where from? By what means? How long before
all the data is received at the centre? If it is to be collected at district health offices, are there
other priority activities which occur annually in the district health office at the same time as
the new set of annual service statistics becomes available thus delaying the WISN data
collection?
At this stage some of these items must be estimated, but the exercise of doing so is most valuable
in clarifying and sharpening ideas about what alternatives should be considered and what will be
practicable in the circumstances of the MOH. This in turn will help determine what should be
implemented.
A brief description of how the new procedure is intended to operate once it is established should
be included with the implementation workplan and budget which is put to the steering committee
for its consideration (see below).
34 _________________________________________________________________________________________
8. Workplan and budget for implementation

The workplan for the implementation activities should cover the following steps:
1. Determine the Activity Standards for the categories of staff to be covered in the exercise (as
set out in the objectives, see point 1). These figures are a vital part of the calculations and
must be available before any WISN results can be produced. This will entail holding a half-
or one-day meeting for each cadre or a two- or three-day workshop to cover all the cadres
in one type of facility, e.g. hospitals. The two different approaches are described in point
4. This should be one of the first activities in the workplan schedule.
2. Convert the Activity Standards set by the professionals (unit times, rates of working, fixed
time allowances, etc.) for each staff category into the corresponding standard (annual)
workload figures to be used in WISN calculations. These calculations are set out in Section
C.3. This must be completed before the calculations can be set up on the computer
spreadsheets.
3. Set up on the computer the data entry format and the calculations of staff requirements for
each type of health facility (see Section C.5). This must be done after 1 and 2 are
completed. The computer set-up should be tested on the first data collected, to ensure that
it is working correctly.
4. Obtain the data (annual service statistics and current staffing levels) for entry into the
computer. Whether this comes from district health offices or is already at the centre, it is
best to secure a small amount first and use it to test the computer set-up before committing
the task force to the whole of the planned data-gathering exercise.
5. Enter all the data for one District and produce the first district summary table, i.e. listing the
results for all the facilities of one particular type in the district with district totals and
averages (see example, A.7). This tests the instructions in the computer for producing the
tables and provides results for the first training sessions of the users (see step 7 below).
6. Enter the data for the remaining districts to be covered in the implementation exercise and
produce the results according to the objectives which have been set for the exercise (district
summaries, province summaries, national summary as appropriate).
7. Design the training for user managers (materials and exercises for a half- or one-day event).
This is described in point 5. It should be scheduled into the timetable soon after the first
district summary table is produced (see step 5 above) so that these results can be used in
training.
8. Schedule into the workplan regular progress reports to the steering committee.
9. Present the final results and a brief description of the exercise to the steering committee.
If districts are to be covered separately and in sequence, it is most desirable for the workplan
schedule to allow sufficient time to produce the results from the first district(s) and to have them
available as examples when working in the subsequent districts.
_________________________________________________________________________________________ 35
Once the workplan (list of activities to be undertaken, their sequence and the effort required for
each) has been produced it is then possible to determine jointly the task force staffing requirements
(numbers and skills), other resource requirements (access to a computer, computer materials,
transport, etc.) and the timetable for the workplan. These items are interdependent - the larger the
task force the shorter the timetable (within limits). From the workplan a detailed budget should be
produced; this will presumably follow the government budgeting regulations of the country (travel
allowances, per diem, etc.)
The workplan and budget for implementation and a brief description of the proposed design of the
WISN procedure being implemented should be presented to the steering committee for its approval
before implementation starts.
36 _________________________________________________________________________________________
______________________________________________________________________________________________________ Section C – Technical factors
Section C:
Technical factors
This section describes how to deal with the technical/mathematical components which underlie the
whole method and which apply to calculating the Staffing Requirements for all staff categories.
Contents
1. Determining available working time per year .................................................................. 37
How to calculate for each staff category, the amount of time available per year
for delivering health services, taking account of the time spent on training, vacations,
sickness and other absences.
2. Setting Activity Standards ................................................................................................ 43
How to set the Activity Standards for the main activities and functions undertaken by
each staff category employed in health facilities.
3. Turning Activity Standards into Standard Workloads ..................................................... 56

Translating Activity Standards (activity times, rates of working, time allowances)
into the equivalent Standard Workloads (the volume of work done in one year) for use
in the calculations.
4. Using standard workloads and allowance standards to calculate staffing requirements .. 61

The procedures and format for performing the WISN calculations.
5. Computerization of the WISN calculations ...................................................................... 65

The principles and main guidelines for implementing the computerization of the
WISN calculations and producing tables of results.
Annex A – Staffing requirements for time-specified posts ........................................................ 69

Annex B – Instructions for groups which are setting activity standards .................................... 71
1. Determining available working time per year

The WISN Method is based on the calculated Standard Workload for each staff category in each
type of health facility. This Standard Workload is the amount or volume of work in delivering
health services which can be accomplished during the course of a year by a competent and
motivated staff member working to acceptable professional standards. Health professionals can
deliver their services only during the time which they actually spend on the job, that is, allowing
for time spent away from their duties during the year on vacation, sickness absence, training, etc.
The calculation of the time which is available from staff to undertake work tasks is designed to
cover all situations including those countries where the working days are not all of equal length,
e.g. a short day is worked before or after the weekly break, and also in order to cover those staff
who undertake shift or night working.
_________________________________________________________________________________________ 37
The calculation of the health personnel required to perform the current workload (i.e. to deliver the
volume of services which is shown in the annual service statistics) must take account of the fact
that sometimes employees are quite legitimately not available to deliver services at their normal
place of work throughout the whole year because of:
1. Vacation: assumed to be a fixed number of working days per year according to regulations;
the length of annual vacation may be different for different staff categories.
2. Public holidays: assumed to be a fixed number of working days per year according to
regulations, which is the same for all staff categories.
3. Off-the-job training: courses, conferences, workshops, study tours, etc. which are (or should
be) approved in advance according to staff development policies. This is usually not a set
number of days per year for each staff member, and so an average per staff member must
be obtained, which may differ according to staff category. The average may be obtained
from training statistics if they are available. Alternatively it is frequently good enough to
have this average estimated for a staff category by the group which is setting the Activity
Standards (unit times or rates) for the category (see Section C.2 below).
4. Sickness and all other absence: an estimated average number of days absence per year which
may differ according to staff category. The average number of days per staff member may
be obtained from personnel statistics if they are available. Alternatively it is frequently good
enough to have this average estimated for a staff category by the group which is setting the
Activity Standards (unit times or rates) for the category (see Section C.2 below).
The steps in the calculation are the same for every staff category:
a) total the number of days per year for the items 1-4 above; this is the average number of
working days per year on which a staff member is not available for delivering services and
for which a correction must be made;
b) divide the total from (a) by the number of working days in the week (e.g. 5, 5.5 or 6) to
obtain the equivalent number of weeks in the year for which a correction must be made;
c) subtract the result in (b) from 52; this gives the number of weeks in the year on average for
which this category of staff is available to undertake normal service delivery activities;
d) multiply the result in (c) by the statutory number of working days in a week (5, 5.5 or 6 as
in (b) above); this gives the average number of days in the year for which this category of
staff is available to undertake normal working duties;
e) multiply the result in (d) by the statutory number of working hours in a full working day; this
gives the average number of hours in the year for which this category of staff is available
to undertake normal working duties.
Example 1
The working week is six days of six hours per day, i.e. 6 days x 6 hours per day = 36 hours per
week. All staff categories:
38 _________________________________________________________________________________________
- have five weeks annual vacation

- are away from the job for training on average for two weeks per year
- have on average 10 days per year of sickness and other absence.
In the country there are 12 days statutory public holiday per year.
Calculation
1. Vacation days/yr (5 weeks x 6 days/week) = 30
2. Public holidays days/yr 12
3. Training days/yr (2 weeks x 6 days/week) = 12
4. Absences days/yr 10
a) TOTAL unavailable days/yr 64

b) Unavailable weeks/yr (divide by 6) 10.7
c) Available weeks/yr (subtract from 52) 41.3
d) Available days/yr (multiply by 6) 248
e) Available hours/yr (multiply by 6) 1,488
Usually statistics are not available on training days and absence days per year (items 3 and 4
above), and it is necessary to obtain estimates for each staff category which is being covered in the
WISN calculations. These estimates are best supplied for each staff category by the groups setting
the Activity Standards for the staff category (see Section C.2).
The figures shown in items (c), (d) and (e):
41.3 available weeks per year

248 available days per year
1,488 available hours per year
are actually the same piece of information (available time per year) expressed in three different
ways - in weeks, days and hours. It is useful to calculate all three figures. They are frequently all
used in the calculation of Standard Workloads because some unit times, rates or allowances will
be set per week, some per day and some per hour.
Sometimes unit times, rates and allowances are set per month, e.g. pharmaceutical assistants in the
country spend two days per month for stocktaking in dispensaries. The average available working
time per month (averaged over the year) is calculated from:
Available days per year

Available working time per month =
12
_________________________________________________________________________________________ 39
Thus the available working time per month in the example above is:
248 days/year
= 20.7 days/month
12
If pharmaceutical assistants in the country spend two days per month stocktaking, then this activity
occupies:
2/20.7 = 0.097 = 9.7%
of their available working time.
Example 2
The working week is five days of eight hours per day and one day of four hours, i.e. 5.5 days or
44 hours/week. A senior staff category (A), e.g. medical officer
has six weeks annual vacation;
is away from the job for training on average for three weeks per year;
has on average five days per year of sickness and other absence.
A more junior staff category (B), e.g. medical aide

has four weeks annual vacation;
is away from the job for training on average for one week per year
has on average 15 days per year of sickness and other absence.
There are 10 days statutory public holiday per year for all staff.
Calculation
Category A Category B
(Medical officer) (Medical aide)
1. Vacation days/yr 6 x 5.5 = 33 4 X 5.5 = 22
2. Public holidays days/yr 10 10
3. Training days/yr 3 x 5.5 = 16.5 1 x 5.5 = 5.5
4. Absences days/yr 5 15
a) Total unavailable days/yr 64.5 52.5
b) Unavailable weeks/yr (divide by 5.5) 11.7 9.5
c) Available weeks/yr (subtract from 52) 40.3 42.5
d) Available days/yr (multiply by 5.5) 222 234
e) Available hours/yr (multiply by 8) 1,776 1,872
Although calculations for only two staff categories are shown here, more columns could be used
to perform the corresponding calculations for as many different staff categories as is necessary, i.e.
where there are different figures in any of the items 1-4.
40 _________________________________________________________________________________________
The figures shown in items (c), (d) and (e) for Category A, i.e.
are actually the same piece of information (available time per year for staff in Category A)
expressed in three different ways – in weeks, days and hours. The corresponding figures for the
available time in a year for staff in Category B are:
The average available working time per month for these staff categories is:
222 days/year
Category A: = 18.5 days/month
12
234 days/year
Category B: = 19.5 days/month
12
The results of calculating the average available working-time per year for different staff categories
can be used directly to calculate the Staffing Requirements of posts which must be manned
according to a fixed time pattern rather than according to workload, for example, an office
receptionist post which must be staffed continuously throughout the year during normal working
hours irrespective of the number of callers, a hospital pharmacy in-charge post which must be
staffed while the pharmacy is open for business irrespective of the volume of dispensing being
done, a security guard post or an intensive care unit post, which must be manned day and night
continuously throughout the year. Examples of these calculations are shown in Annex A.
On-call service
One type of working arrangement, on-call service, does not fit into the calculations of available
working-time per year given above. In on-call duty, staff are available for service during official
off-duty hours at nights and weekends and they work during this period only when there is a
demand for their services. This is frequently the arrangement with laboratory and X-ray staff in
the smaller hospitals, particularly those which operate 24-hour accident and emergency services,
and also with midwifery staff. Arrangements for on-call service differ. Sometimes the on-call staff
are available within the health facility itself; they are provided with a room there but they are not
disturbed until their services are required. Alternatively, particular staff are nominated as being
on-call and are brought in from their own homes when needed. The question arises as to what
levels of staffing are required to cover on-call service as well as duty during normal working hours.
The accommodation arrangements for staff on on-call services are irrelevant to the WISN
calculation. The sole factor of importance is the method of recompense used for on-call duty. Two
main methods are used: time off in lieu and extra payment.
_________________________________________________________________________________________ 41
In some countries a proportion of the on-call duty time is given as time off in lieu. This proportion
may be 100%, i.e. the whole of the on-call time is counted as duty time, so that a night on-call
(4.00 p.m. – 8.00 a.m., i.e. 16 hours) is followed by two days (8-hour shifts) off. More usually the
arrangement is that a night or week on-call is followed by one day or week off, since normally the
workload at night is very light. For WISN purposes the actual duration of the on-call time is
ignored and the time off in lieu is counted as ordinary working time. Thus if a facility uses on-call
duty as a permanent feature of its staffing arrangements, then the calculation of its Staffing
Requirement has two components:
- staff required to cope with the normal workload as shown in the service statistics, calculated by
the WISN Method;
- the staff equivalent of the time off in lieu.
For example, a large health centre schedules a particular category of staff for day duty on rota for
seven days a week and covers all (365) nights by having one person on-call with the following day
off. This on-call duty requires extra staff, which is equivalent to 365 days service per year.
Suppose, for the sake of example, that staff in this category are available for duty on average for
234 days per year, like the medical aides in the example earlier. Then the extra staff required is
365 / 234 = 1.56 staff. The calculated Staffing Requirement for the facility is then:
staff requirements according to the WISN Method based on service statistics PLUS
an extra 1.56 staff for the on-call duty.
This does not mean that one or two staff are appointed solely for on-call duty but rather that the
on-call duty is shared among all the staff and this will be possible only by employing one or two
more staff.
If the on-call time is recompensed by payments (at whatever rate) and not by any time off in lieu,
then it is not counted as part of the WISN calculations. In effect, the extra on-call duty time is
provided by staff out of their own off-duty time and does not affect their ordinary working time.
Other types of arrangement, e.g. a different amount of time off for the on-call duty, on-call duty
at weekends only, etc. is treated in the same way by focusing solely on the average amount of time
off in lieu which is given in a year, and the extra staff which will be required to cover it. If it is a
mixed arrangement, with both extra payments and time off in lieu, only the time off in lieu is
included in the WISN calculations.
Scheduled/actual working hours

In nearly all countries there are situations where the actual hours worked by staff are less than the
scheduled working hours specified in the conditions of service or the contract of employment. This
may be general or it may apply to only certain categories of staff and/or certain types of health
facility and/or certain locations. One possible reason for this is that the public attends for treatment
only at particular times. For example, in one rural health facility with working hours 8.00 am to
3.00 pm (seven hours/day), the public attended only 8-10 am and 1-3 pm, that is four hours/day.
Or the staff themselves may curtail their working hours because of private practice or other
earning activities, or because it is the custom and practice, etc. In all these circumstances the
question arises as to how to frame the WISN calculations, i.e. whether to use the formal contracted
hours (e.g. seven hours/day) or the actual working hours (e.g. four hours/day) in order to set the
Standard Workloads (the amount of work one staff can do in a year).
42 _________________________________________________________________________________________
The decision as to which to use depends on whether the situation is outside the effective control
of the MOH. For example, it would be realistic to use the attendance times of the public, say four
hours out of seven hours per day, in the short term because these are determined by social or
cultural factors, although the ministry may attempt to change these in the medium to long term by
an education process to encourage the public to attend during the current dead periods, or it may
attempt to reduce the financial burden of the situation by instituting part time employment of staff
(e.g. 08.00-10.00 and 13.00-15.00 daily) if possible. If the situation is theoretically within the
authority of the ministry, e.g. staff leaving early to attend to private practice or other activities, the
decision is more difficult. Using the formal working hours gives results of what the government
is entitled to – it shows the staffing which the government is entitled to expect will do the job, i.e.
carry out the workload to an acceptable professional standard. This is usually strongly favoured
by departments of finance. Using actual working hours shows the staffing levels that will be
required if the current situation continues. This is usually strongly favoured by local managers.
As an entirely separate issue (from which time to use in the calculations) is the question of how to
calculate the results if the actual working hours are used to set Standard Workloads. The manual
shows how to set up the calculations using formal or contract working hours. To use actual
working hours in the WISN calculations there are two options:
1. Insert the actual working hours instead of the formal working hours in the calculation of the
working time available per year as set out in the manual. This will probably mean repeating
these calculations for several different categories of staff.
2. Use the formal working hours in the calculation of the working time available per year as
set out in the manual and include the "missing" hours, i.e. the formal or contract hours per
day which are not worked, as an extra allowance in the later calculation of Standard
Workloads (see Section C.3). The WISN Method is already set up to take account of
different allowances for different categories of staff. This extra allowance can easily be
adjusted in the calculations if the situation should change.
2. Setting Activity Standards

An Activity Standard must be set for each type of health care activity. An Activity Standard is a
unit time (or rate) for a health care activity – how much time, on average, performing an
examination, filling a prescription, taking an X-ray, etc. should take to complete by qualified staff
who are working to acceptable professional standards. These Activity Standards are a vital factor
in the WISN calculations; they have a direct effect on all the results that are produced. Also,
setting these Activity Standards is a novel procedure in virtually all countries and so the staff who
undertake it must be carefully oriented before the procedure and guided during it if they are to
perform the task successfully. For these reasons the procedure to use in setting Activity Standards
is set out in some detail.
The Activity Standards for health staff in a country are usually set by working groups of senior and
knowledgeable staff with substantial experience of the work for which the standards are being set.
Two different types of working group can be used to set Activity Standards:
- a cadre group, which consists of the senior and knowledgeable staff in a cadre who set the
Activity Standards for all the staff categories in their own cadre working in all the different
types of health facilities in which the cadre is employed in the country. Using this approach,
each cadre employed in the health service requires a cadre group to set its Activity Standards;
_________________________________________________________________________________________ 43
- a facility group, which consists of the senior and knowledgeable staff in a health facility which
is generally reckoned to have good performance. Together the group sets the Activity
Standards for all the staff categories who work in this type of health facility in the country. In
theory each type of health facility requires a facility group to set the Activity Standards of the
staff employed in it. However, in practice if the activities carried out in one type of health
facility are very similar to those carried out in another, e.g. dispensary/health centre or
regional/national hospitals, one facility group can produce the Activity Standards for the staff
in both types of facility, even where the Activity Standards for an activity may be different in
the two types of facility.
In order that these groups can perform their task and produce results which will be useful in the
WISN calculations, the participants in these groups must be oriented to understand the steps in the
procedure:
a) What is an Activity Standard?
b) What is the scope of their task, i.e. which staff categories and facilities are they to cover in
producing Activity Standards?
c) What are the main activities or functions (components of workload) for each of these staff
categories in each type of facility in which they are employed?
d) Setting an Activity Standard for each of the main activities or functions (components of
workload) in each type of facility.
e) Estimating the amount of time spent away from the working situation on staff training and
different types of absence.
Each of these steps is explained in the following subsections, which could be used as the
introductory material/presentation to these groups.
a) What is an Activity Standard?
The Activity Standard for a particular activity is the time it would take a trained and well-motivated
member of a particular staff category to perform the action to acceptable professional standards in
the circumstances of the country (its medical practices, equipment available, etc.). In the WISN
Method, all Activity Standards are set in terms of the time taken to perform certain actions or the
rate at which these actions should be performed.
b) What is the scope of the group's task, i.e. which staff categories and facilities are to be
covered?
Activity Standards can be set for a cadre by a group of senior and knowledgeable staff in the cadre.
This is known as the "cadre group" method. The group sets the Activity Standards by reviewing
the work of each of the staff categories in the cadre in each type of health facility in which they
work in the country. For example, a pharmacy group setting Activity Standards in one country set
out its task as follows:
44 _________________________________________________________________________________________
Pharmacy group
Staff categories senior pharmacist; pharmacist; pharmaceutical assistant;
pharmaceutical attendant
Facilities national hospital; regional hospitals; district hospitals; health
centres
In setting out its task, the group took account of the fact that:
a) Senior pharmacists are employed as the person in charge of pharmaceutical services in the
national and regional hospitals. The job of the senior pharmacist is the same in national and
regional hospitals, so only one set of Activity Standards is required for this staff category.
b) Pharmacists are employed in the national, regional and district hospitals. The job of a
pharmacist is the same in a national and a regional hospital (mainly filling prescriptions) but
has extra tasks and responsibilities in a district hospital (where the pharmacist is the person
in charge of the pharmacy), so two sets of Activity Standards for pharmacists are required
for this staff category.
c) Pharmaceutical assistants are employed in the national, regional and district hospitals and
in health centres. The job of a pharmaceutical assistant is the same in national, regional and
district hospitals but has extra tasks and responsibilities in a health centre (where the
pharmaceutical assistant is the person in charge of the pharmacy).
d) Pharmaceutical attendants are also employed in the national, regional and district hospitals
and in health centres. The job of pharmaceutical attendants in cleaning, replenishing stocks,
etc. is the same in all the health facilities.
The Activity Standards to be determined by the group were then set out in a table:
Senior pharmacist national/regional hospitals

Pharmacist 1. national/regional hospitals
2. district hospitals
Pharmaceutical assistant 1. national/regional/district hospitals
2. health centres
Pharmaceutical attendant national/regional/district hospitals/health centres
Similarly the laboratory group set out its task as follows:
Laboratory group
Staff categories laboratory technologist; laboratory technician; laboratory
assistant; laboratory attendant
Facilities national hospitals; regional hospitals; district hospitals; health
centres
The group determined that the job (and hence Activity Standards) of laboratory technologist was
the same in the national and regional hospitals (where a pathologist is in charge of the laboratory)
_________________________________________________________________________________________ 45
but different in district hospitals (where the laboratory technologist is in charge); that the laboratory
technician has one job (set of Activity Standards) in hospitals and a different job (set of Activity
Standards) in health centres where the laboratory technician is in charge; and that the job (Activity
Standards) of a laboratory attendant in cleaning, replenishing stocks, etc., is the same in all health
facilities.
As before, the Activity Standards to be determined by the group could then be set out in a table:
Laboratory technologist 1. national/regional hospitals

Laboratory technician 1. national/regional/district hospitals
2. health centres
Laboratory attendants national/regional/district hospitals/health centres
Doctors group
Following the same procedure, the doctors group set out its task as follows:
Staff categories consultant; registrar; medical officer; medical assistant; rural

medical assistant
Facilities national hospitals; regional hospitals; district hospitals; health
centres; health posts
Here again the job of each staff category (and hence its Activity Standards) was different
depending on the type of health facility. For example, consultants in the national hospital undertook
more complex cases (more time per case) and more research (larger time allowance for this
activity) than the consultants working in the regional hospitals, while in the district hospitals
consultants are in charge of departments and so have a major management function there (requiring
a corresponding time allowance); registrars work only in the national and regional hospitals, where
the training posts are available; medical assistants work in district hospitals and also in health
centres (where they are in charge); rural medical assistants work in health centres and also in health
posts (where they are in charge).
The Activity Standards to be determined by the group could then be set out in a table:
Consultants 1. national hospital

2. regional hospitals
3 district hospitals
Registrars national/regional hospitals
Medical officers 1. national/regional hospitals
Medical assistants 1. district hospitals
2. health centres
Rural medical assistants 1. health centres
2. health posts
46 _________________________________________________________________________________________
A cadre group can be set up for any cadre employed in the health service, in order to set the
Activity Standards for all the categories of staff in the cadre in all the types of health facility in
which they are employed in the country.
Alternatively the Activity Standards can be set for all the staff categories employed in one type of
facility by a group of senior staff who between them are knowledgeable about all the activities of
all staff categories employed in this type of facility. This is known as the "facility group" method.
These groups set out their task by listing all the staff categories which are employed in this type
of facility, for which Activity Standards must be set. Some examples are:
Health post group

Staff categories rural medical assistant; MCH aide; nursing assistant; nursing
attendant; health assistant
Health centre group

Staff categories medical assistant; rural medical assistant; MCH aide; nurse
midwife; nursing assistant; nurse attendant; laboratory assistant;
medical records assistant; health assistant; cooking staff;
laundry staff; driver; watchman
The same method can also be used for clinics and other relatively small health facilities. However,
when this facility group approach is used for hospitals, particularly the larger hospitals, it would
be unwieldy and inefficient to follow exactly the same format. A list of the staff categories
employed in a large hospital is exceedingly long and must be divided up in some way to make the
work practicable. The most convenient way of doing this is to combine the two methods, that is,
first to make a list of all the hospital staff categories (the facility group approach) and then to divide
the list by cadre (the cadre group approach). For example, the task of setting Activity Standards
for the laboratory staff in a large hospital was set out as follows:
Regional hospital: laboratory group

Staff categories laboratory technologist; laboratory technician; laboratory
assistant; laboratory attendant
and the task of setting Activity Standards for the radiography staff was also set out simply:
Regional hospital: radiography group

Staff categories senior radiographer; radiographer; radiographic (darkroom)
assistant
However some staff categories in a large hospital, e.g. nurses, work in many different locations and
do many different jobs. For this reason the regional hospital nurses group had a rather larger task,
which was most conveniently set out in the facility/cadre group format, as follows:
_________________________________________________________________________________________ 47
Regional hospital: nurses group

Staff categories nursing officers; nurse midwives; registered nurses; enrolled
nurses; nursing assistants; nursing attendants
Facilities general medical wards; paediatric wards; psychiatric wards;
maternity wards; general surgery theatres; obs. & gynae.
theatres; eye surgery; outpatient clinics; MCH/FP clinics;
ophthalmic clinics; psychiatric clinics; accident & emergency
department; intensive care unit.
It is a major task to set Activity Standards for all the different combinations of nurse staff
categories and the types of work they do in a large hospital. One simplification which is frequently
used is to group together types of ward or types of clinic and set average Activity Standards for
each of these groupings, e.g. the wards (general medical/paediatric/psychiatric wards but not
including maternity wards); maternity wards; all operating theatre work; all clinics; etc. Even
where this simplification is used the situation is still fairly complicated because different nursing
categories are employed in each of the working situations. These complications are best clarified
by setting out a matrix (two-way table) showing the staff categories down the side and the facilities
or working situations along the top. An example from one country is as follows:
Operating Acc. &

Nurses group Wards Maternity Clinics
theatres emergency
Nursing officer x x x
Nurse midwife x x
Registered nurse x x x x
Enrolled nurse x x x
Nursing assistant x x x x x
Nursing attendant x x x x
Each "X" denotes a set of Activity Standards which had to be produced. In some cases the
activities of a nursing category, e.g. nursing attendant, are the same in several working locations
and the same Activity Standards can be used in all of them.
The same situation arises with the medical staff in a large hospital (several different categories of
medical staff working in a number of different situations), and the same approach of setting the
task out in matrix form works well in this case also.
In one country four main facility groups were assembled:
Health post group: comprising eight district-level staff and people in charge of health centres with
long experience of supervising health posts, and representatives of MOH departments.
Health centre group: comprising ten district-level staff and people in charge of health centres with
long experience of supervising health centres, and representatives of MOH departments.
District hospitals group: comprising the senior staff from all departments in one high performance
district hospital, and representatives from the regional health team and MOH.
48 _________________________________________________________________________________________
Regional and national hospitals group: comprising senior staff representing all departments from
the national hospital and the best regional hospital, together with representatives from MOH.
The health post group met and took half a day to complete its work on setting Activity Standards
for the five staff categories (listed above) employed in the health posts. Subsequently the health
centre group, which included many of the same individuals, took one day to complete its work on
setting Activity Standards for the thirteen staff categories (listed above) employed in health centres;
some of the categories, e.g. driver and watchman, could be dealt with very quickly.
The meeting of the district hospitals group and of the regional and national hospitals group took
the form of workshops. In these, an initial plenary session introduced the task, explained its
content and described the procedures to be used (based on the material set out earlier in this
section). Then the participants listed all the cadres/staff categories and working situations
(wards/clinics/theatres etc.) to be covered. Participants were then divided into a number of
working groups at each session, and each working group produced the Activity Standards for one
of the cadres employed in the hospital. In each workshop session the chairman and secretary of
each working group both came from the cadre being considered by the working group. The
Activity Standards produced by each working group were reported back to a plenary meeting of
the workshop for consideration and approval. Some cadres (radiography, pharmacy) occupied a
working group for half a day, but others (doctors, nurses) took a full day or more. The workshop
for the district hospitals group lasted three days, and for the regional and national hospitals group
five days.
In addition each of the specialist hospitals, i.e. TB hospital, eye hospital, etc., set up its own group
of senior staff which was joined by representatives of MOH. Each of these specialist hospital
groups set the Activity Standards for all the staff categories employed in their own hospital.
Wherever possible these Activity Standards were the same as those set out for staff in the national
hospitals.
Whichever method (cadre group or facility group) is being used to set Activity Standards, each
group should first set out the task it is to tackle under the headings of:
- staff categories, in order to list all the different types or grades of staff it is to cover;
and where appropriate
- facilities, in order to list all the different working situations it is to cover.
Only then should the group decide which jobs are the same so that the same Activity Standards will
apply. It is very desirable to draft out beforehand a list of the staff categories and facilities for each
cadre group, facility group or working group in a workshop so that it can start its task by correcting
the draft lists if necessary and thereby understand the extent of its work from the start.
c) What are the main activities or functions (components of workload) for each of these staff
categories?
Having decided which staff categories/working situations need to have Activity Standards set, the
next step is to determine what activities or staff functions should be covered by these Activity
Standards. Most staff categories employed in a health facility each has a number of major func-
tions or activities which it performs. These are the functions or activities which together take up
most of the working time of the staff concerned. These major functions or activities are called the
components of workload for the staff category in the health facility. There are usually not more
_________________________________________________________________________________________ 49
than three or four components of workload for each staff category. For example, the main tasks of
a pharmaceutical assistant in a district hospital are:
filling prescriptions
preparing materials and cleaning up
These are performed under the supervision of the pharmacist in charge of the hospital dispensary.
Each of these components of workload must have its Activity Standard.
However, the components of workload for a staff category depend on which types of health facility
they are employed in. To continue the example, the same staff category working in a health centre,
where the pharmaceutical assistant is in charge, has additional tasks. Not only
filling prescriptions
preparing materials and cleaning up
as in the district hospital, but also

recording and reporting
ordering stock, checking deliveries and supervising storage.
The workload of the pharmaceutical assistant in the health centre must take account of these extra
tasks and the time they take. These two extra components of workload must each have its own
Activity Standard also.
In one country the registered nurses in health centres (where a medical assistant is in charge) have
the following main activities:
inpatients
outpatients
scheduled clinics
supervised births
recording and reporting.
The nursing aides in the same health centres have only two main activities:
inpatients
outpatients.
It is a matter of judgement to decide what level of detail to go to in listing the components of

workload for a staff category. For example, the main components of workload for a dental
assistant in a district hospital could be listed as:
treating patients
setting out and clearing away
recording and reporting
and an Activity Standard could be set for each of them.
However the first item, treating patients, could be broken down into:
extractions
fillings
scaling
polishing
with each of these items having its own Activity Standard (average time to perform each type of
treatment).
50 _________________________________________________________________________________________
Similarly the components of workload for laboratory assistants could be:

performing tests
specimen collection
record keeping.
Here again the first item, performing tests, could be broken down into:
haematology
bacteriology
parasitology
clinical chemistry
immunoserology
with an Activity Standard (average time to complete) set for each type of test.
This same type of detailing can be done with the components of workload for all categories of staff,
e.g. inpatients can be divided into medical/surgical/paediatric/psychiatric etc., filling prescriptions
can be divided into one item/two item/three item prescriptions, etc.
Working in more detail like this gives the possibility of more precise results from the WISN
calculations. However, it does require more effort - both in collecting much more data (frequently
a great deal more) and also in entering this larger volume of data into a computer.
Although the level of effort required for the WISN calculations is an important factor in deciding
what level of detail to work at in applying the method, an even more important factor is the level
of detail currently available in the service statistics which are regularly collected in the different
health facilities and returned by them to the local district or regional health office or to the centre.
The WISN calculations can be performed only to the level of detail in the statistics themselves. If
these statistics show only the total numbers of dental patients treated and not the numbers receiving
each type of treatment (extractions, fillings, etc.), then the calculations can only be done and the
Activity Standards should only be set in terms of the total number of patients treated and not the
numbers of extractions, fillings, etc. which are done. Similarly if a single bed occupancy figure
is available for each hospital rather than the occupancy figures for each type of ward (medical,
paediatric, etc.), then Activity Standards must be set for nurses in the hospital as a whole rather
than for individual wards. Such average Activity Standards may be thought of as crude, but they
are much more effective in setting realistic Staffing Requirements than the usual alternatives
(population ratios, standard staffing schedules).
d) Setting an Activity Standard for each of the main activities or functions (components of
workload) for each staff category
When the components of workload have been identified for all the staff categories in each type of
facility in which they are employed, each group then sets an Activity Standard for each component
of workload. In undertaking their task, the groups set two types of Activity Standard:
a) Standards for the services and activities which are reported in the annual service statistics,
e.g. number of inpatients (or bed occupancy) in various types of ward, number of outpatient
visits, number of clinic patient visits of various types, number of births, number of
major/minor surgical operations, number of dental treatments of different types, etc. In the
calculations these standards are applied to the reported workloads which are shown in the
latest annual service statistics. They are called service standards.
_________________________________________________________________________________________ 51
b) Standards which apply to those activities which are not reported in the annual service
statistics. This may be because the activities cannot easily be measured, e.g. recording and
reporting, stores management, performing ward procedures, attending meetings, general
administration, etc. Alternatively this may be because the regular collection of service
statistics in the country does not yet cover these activities, e.g. in some countries the number
of laboratory tests performed in health centres are not reported. An allowance is made in
the calculations for these activities according to the amount of working time they should
absorb. These are called Allowance Standards.
The first step in setting the Activity Standards for a staff category working in a particular type of
facility is to mark each of its components of workload according to whether it is covered in the
regular service statistics which are readily available in the country (and so must have a service
standard) or whether it is not (and so must have an Allowance Standard).
In many cases a component of workload corresponds directly to an item in the regular service
statistics:
- inpatients or bed occupancy, for the workloads of doctors, nurses and most ward staff;
- tests performed, for the workloads of laboratory staff;
- outpatient visits, for the workloads of staff in health posts, health centres and the outpatient
departments of hospitals;
- antenatal examinations, child weighings, immunizations, etc., for the workloads of staff in MCH
clinics.
In other cases a component of workload is clearly related to the general level of workload in a
health facility, but a directly relevant item of data is not collected and included in the regular
statistics. For example, the workload of hospital laundry staff increases directly as the general
level of workload in the hospital itself increases. In countries where the number of items washed
is recorded, the statistics provide an item of data which corresponds directly to the main component
of workload of this staff category. However most countries do not collect statistics on the volume
of laundry processed in hospitals, and so it is necessary to find a proxy item, i.e. an item of data
which will serve as a proxy measure of the volume of laundry to be done. The item of data most
frequently used for this purpose is the number of inpatients, or bed occupancy. The group estimates
how many laundry staff would be required to deal with bed linen from 100 inpatients, and this then
serves as the Activity Standard. Similarly, in countries where kitchen staff are employed to
provide food for inpatients and/or staff in health facilities, the number of meals provided per day
is not recorded. However, the number of meals daily can be estimated from the service statistics
as:
3 x (no. of inpatients + no. of staff eligible for meals).
The group sets an Activity Standard as the number of kitchen staff required to prepare 100 meals
per day.
Wherever possible, components of workload should be linked to items in the service statistics,
either directly or by proxy. Only if no relevant statistics are collected or if the activity is
independent of the service workload, or very nearly so, should an Allowance Standard be set; the
way of doing this is set out later.
52 _________________________________________________________________________________________
For each of the components of workload which is covered by or linked to an item in the regular
statistics, the group should:
a) specify the statistics item to be used, e.g. outpatient visits, antenatal examinations, home
deliveries, X-ray examinations, clinic attendances, inspections of premises, etc.
b) set an Activity Standard as a unit time for the item, e.g. 10 minutes/outpatient visit, four
hours/home delivery, 15 minutes/X-ray examination, etc.
c) alternatively, for some activities it is easier and more natural to set an Activity Standard in
terms of a rate of working, e.g. 40 clinic attendances per day for a nurse, six inspections per
day for a health assistant, etc.
In setting a unit time as an Activity Standard, e.g. for an outpatient visit, laboratory test, home
delivery, dental treatment, X-ray examination, etc., it is important to include in the unit time all the
tasks related to the individual item, e.g. a doctor writing up a patient's notes after the consultation,
recording the results of each laboratory test twice (once for the laboratory records and once for the
doctor who sent the sample), setting out and clearing away for each dental patient, etc. The unit
time is the average time which should elapse between the start of an item of service activity (out-
patient visit, laboratory test, etc.) and the start of the following item of the same activity if all
procedures are working efficiently according to practices of the country and there are no delays
between successive items of service activity. Anything done for each patient or item should be
included in the unit time for each patient or item, e.g. recording and reporting. Anything done
regularly (once a day, a week, a month, etc.) irrespective of service workload, should be covered
by an Allowance Standard, e.g. daily, weekly, etc. reports.
It is normally better, wherever possible, to set a unit time for a component of workload rather than
set a daily or weekly rate, for two reasons. First, it is easier to visualize a single activity (outpatient
examination, laboratory test, dental treatment, etc.) and estimate its duration. Thus an estimate of
an actual elapsed time for an activity is likely to be more accurate than a rate. Certainly
discussions within groups are more specific and disagreements more quickly resolved. Second,
when the groups set a daily rate, for example, it is never quite clear to what extent they are
including an allowance for other activities, e.g. recording and reporting, setting up and clearing
away, supervision, etc. If it is clear that these allowances are included in the rates set by a group,
then the allowances should not be included as separate Allowance Standards in the subsequent
WISN calculations.
Hospital ward staff who deal directly with inpatients (mainly nurses) merit a special procedure in
this method. It is possible to use the standard approach and set a unit time per patient for those
ward staff whose main work consists in dealing with inpatients, and this method has been used in
some countries. In this approach an estimate is made of the average amount of time in total which
a nurse (or other category of ward staff) should give to each inpatient during a 24-hour period. This
average time is then used as the Activity Standard. However, the Staffing Requirements of ward
nurses and other ward staff are best calculated using another type of Activity Standard, which is
to specify the number of inpatients (occupied beds) for which a nurse on duty should be
responsible, e.g. one nurse per 10 occupied beds. This figure can vary with the shift, e.g. one nurse
per eight occupied beds on the morning shift, one per 12 occupied beds in the afternoon shift and
one nurse per 20 occupied beds during the night. It can also vary with the type of ward (it is
usually smaller for paediatric wards, e.g. one nurse per five occupied beds, than for general medical
wards, e.g. one nurse per 10 occupied beds, and for intensive care units it can be one nurse for each
occupied bed.) One major advantage of this method is that it is much easier for nurses to estimate
_________________________________________________________________________________________ 53
how many inpatients they can cover adequately when on duty than it is for them to add up the total
average time which should be spent with each patient totalled over three shifts during a 24-hour
period. And because the number of inpatients (occupied beds) covered conforms with their direct
work experience, rather than the average accumulated time spent with each inpatient over a 24-
hour period, these estimates are not only easier for them to make but more accurate as well.
Figures for nurse/inpatient ratios for different types of wards should only be set where the regular
service statistics show bed occupancy rates separately for each of these types of ward. If bed
occupancy rates are known only for the hospital as a whole, then groups should set a
nurse/inpatient ratio for the hospital as a whole.
For each of the components of workload which is not covered by an item in the regular statistics,
the group must set an allowance either as a percentage of working time, e.g. 20% for administration
by the person in charge of a laboratory, or as a time allowance, e.g. one hour per day for recording
and reporting by ward nurses, five hours per week for clinical meetings of hospital doctors, two
days per month for checking and replenishing supplies by pharmaceutical assistants in a
dispensary.
This allowance may apply to all the staff in a particular category, e.g. all doctors in a particular
type of hospital attend clinical meetings for five hours per week; all pharmaceutical assistants
working in district hospitals spend one hour per day cleaning equipment, utensils, etc. Alternat-
ively the allowance may refer to a task or function performed by one or two individuals only in the
working situation, e.g. one nurse in the ward completes the ward returns, taking one hour per shift;
two pharmaceutical assistants spend two days per month checking and replenishing dispensary
supplies. The group must state clearly for each component of workload for which an allowance
is made, whether the task or function is performed by a fixed number of staff (one, two, ...) or by
all the staff in the category. These two types of allowance (applied to a fixed number of staff or
to all staff) require slightly different mathematical formulae in the WISN calculations.
Some jobs consist wholly of activities (components of workload) which are not directly related to
the workloads shown in the service statistics; in other words if the service workloads in the
facilities changed, the workloads of these jobs would not be affected to the same extent. For
example, the jobs of some staff are wholly or mainly administrative, e.g. staff employed in the
Ministry of Health HQ and in regional and district health offices, hospital secretaries, matrons in
large hospitals, etc. Other staff, usually in the lower grades, may also have jobs which are not
directly related to delivering health services and therefore are not significantly affected by the
volume of service delivery, e.g. cleaners, messengers, gardeners, watchmen, guards, drivers, etc.
But note that the workloads of cooks and laundry staff do depend directly on the number of
occupied beds, which normally appear in regular hospital statistics.
In addition there may be other categories of staff whose jobs are related to service delivery but no
figures on their activities are collected in the regular statistics, e.g. health educators in some
countries, health assistants in some countries, etc. Since no workload statistics are available for
these categories of staff, calculations of Staffing Requirements based directly on workloads are not
possible.
For all those staff where none of their components of workload is covered by an item in the service
statistics, a different type of Activity Standard must be set. This standard must be one of the
following types:
a) A ratio on other staff, e.g. one medical assistant per four rural medical aides in a health
centre (for five or more RMAS the management and supervision workload in the health
54 _________________________________________________________________________________________
centre is too great for one MA), one laboratory assistant per two rural medical aides in a
health centre (where no laboratory statistics were being collected); one nurse supervisor per
30 nurses employed in a hospital. In these cases the number of rural medical aides, hospital
nurses, etc. are calculated from the workload statistics in the health centre, hospital, etc.
using the WISN Method, so the number of medical assistants, laboratory assistants, nurse
supervisors, etc. are also based on workload, but at one remove;
b) A fixed number per facility, e.g. three watchmen per health centre, one matron per hospital,
one nursing attendant per dispensary, etc., whatever the size of facility covered and the
workload in it;
c) A fixed number per item of equipment e.g. one driver per vehicle, two radiographers per X-
ray machine (where no X-ray statistics are being collected);
d) A fixed number per administrative unit, e.g. one health assistant per electoral ward, one
district medical officer per district, etc...;
e) Staffing according to organizational structure, where a number of senior posts are specified,
e.g. director general, deputy directors general, directors, deputy directors, etc. in the
ministry/department of health, regional offices, etc. (In these structures only the numbers
of more junior staff, e.g. at clerical grades, are determined by workload).
In all these cases no separate allowances (for administration, supervision, etc.) are made; these
factors are already included in the types of standard listed above.
Activity Standards for acceptable alternative procedures

In some countries different medical services are provided according to the different cultural
traditions of the country (e.g. Moslem, French, Anglo-Saxon) and these may operate different
medical procedures in order to deal with the same situation (e.g. outpatient attendances). These
different medical procedures normally take different times to perform, i.e. have different Activity
Standards. Provided all these cultural differences are accepted within the country, then separate
Activity Standards should be set for the activities in each of them where they are required. There
should be no attempt to set a single representative or average Activity Standard to cover all the
different practices which deal with the same medical situation; this would simply give an incorrect
result for the Staffing Requirements in some, perhaps all, types of these facilities.
It should be noted that dividing the working time of a staff category between its components of
workload, e.g. for a health sub-centre nurse
40% treating outpatients

10% health education sessions
30% home visits
10% school visits
10% administration
is not setting an Activity Standard. Such a list shows the expected pattern of activities for this
category of staff, but these figures do not show how much work is expected of these staff (how
_________________________________________________________________________________________ 55
many inpatients per day, how many home visits per day), and hence how many of them would be
required in a health facility in order to deal with its recorded workload.
Setting the unit times, rates and allowances is the most critical step in the whole task of calculating
WISNs. It should be emphasized to groups which are setting these Activity Standards that:
a) The unit times, rates and allowances should correspond to the standard of performance
which would be expected of experienced and well motivated staff taking into account the
general situation or circumstances found in these facilities in the country, e.g. medical
practices, availability of equipment and supplies. International comparisons should be made
with the utmost care. Medical practices and equipment differ greatly between countries; also
staff categories with the same title in two countries may be performing very different
functions;
b) Although groups are naturally anxious to set highly professional standards of performance
in the country, their targets cannot be too far from the prevailing practice otherwise the
resulting Staffing Requirements will be so high that they are impracticable and will therefore
be ignored, and the whole WISN exercise will be futile. It is better to set intermediate
targets for Activity Standards which can be improved later as the staffing situation improves.
A sample set of briefing notes and instructions for groups on setting Activity Standards is in
Annex B.
e) Estimating the amount of time spent away from the working situation on staff training and
absence
One component of the calculation of available working time per year (see Section C.1) is making
an allowance for the training time, sickness and other absence times of each staff category. Where
possible these figures are obtained from staffing statistics or personnel records. However in many
countries this is not possible and an estimate of training time and absence time must be made. The
cadre group or facility group which has sufficient knowledge and experience of a staff category
to set its Activity Standards, is also best placed to make these estimates of training time and
absence time. For convenience this task is added to the list of tasks for these groups. The
estimates for training time and absence time may be made separately or as a single figure covering
both, and also they may be set as a percentage of working time or as a number of days or weeks
per year.
3. Turning Activity Standards into Standard Workloads

Once the expert groups have set the Activity Standards for each staff category in each type of
health facility in which they are employed, their task is complete. The service standards are unit
times (e.g. 15 minutes/patient) or rates (e.g. 30 patients/day). The Allowance Standards are
percentages of working time or actual working time (e.g. one hour/day, two days/month, etc.) for
a fixed number of staff or for all staff in the category in the working situation. These standards
must be combined and translated into the equivalent volumes of work per year per employee
(Standard Workloads) so that they can be compared with the volumes of workload reported in the
annual statistics in order to calculate the numbers of staff required. The Standard Workloads are
the figures which are actually used in the computer calculations to produce the Staffing
Requirements. Calculating the Standard Workloads from service standards, and the Allowance
Factors from the Allowance Standards is a job for the task force.
56 _________________________________________________________________________________________
The steps in the process are:
a) Calculate the annual volume of activities according to the service standards alone, i.e. activi-
ties for which unit times or rates have been set;
b) Calculate a multiplier factor based on the Allowance Standards which apply to all staff in
the category, i.e. activities which are undertaken by all staff in the category;
c) Finally, add in the Allowance Factors for tasks or functions performed by a fixed number
of staff in the working situation.
All the examples shown below are based on figures given in Section C.1, Example 2.
Standard Workloads based on unit times

The formula for calculating the annual workload (Standard Workload) for an activity based on the
time required to perform the activity (Activity Standard) is
Available time in the year

Standard workload for an activity =
Unit time for the activity
(Activity standard)
Examples
If the dental screening of a school takes one day and is carried out by a school dental therapist (Cat-
egory B staff), who have available working time of 234 days per year, then the Standard Workload
is
234 / 1 = 234 schools/year
This does not mean that a school dental therapist would be expected to carry out 234 school
screenings every year. These staff also undertake other activities, e.g. administration, equipment
cleaning and maintenance, etc. Rather it means that each school screened takes 1/234th of a
working year for a school dental therapist.
If a major surgical operation takes on average two hours, the corresponding Standard Workload
for category A (medical) staff, with available working time of 1,776 hours per year, is
1,776 / 2 = 888 major operations/year
This does not mean that a surgeon would be expected to carry out 888 major operations in a year
– (s)he has many other activities which take up working time. All these other activities are allowed
for in the calculations. Major operations are only one component of a surgeon's workload. The
result shown actually means that one major operation will take up 1/888 of the working year of a
surgeon.
For Category B (support) staff a major surgical operation takes on average two and a half hours
(15 minutes setting up, two hours operation, 15 minutes clearing away). The corresponding
Standard Workload is:
1,872 / 2.5 = 749 major operations/year
_________________________________________________________________________________________ 57
If a minor operation takes on average 15 minutes, the corresponding Standard Workload for
Category A staff is:
Category A: 1,776 x 60 / 15 = 7,104 minor operations/year
There is no setting out and clearing away between minor operations, only at the end of the
operating session, so the average time requirement for Category B staff is also 15 minutes and the
corresponding Standard Workload is:
Category B: 1,872 x 60 / 15 = 7,488 minor operations/year
In addition there will be an Allowance Factor (see later) included in the calculation to cover the
setting out and clearing away time at the beginning and end of the operating session; this time is
the same no matter how many minor operations (workload) are performed during the session.
If a pharmaceutical assistant (Category B) takes on average five minutes to fill a prescription, the
1,872 x 60 / 5 = 22,464 prescriptions/year
Standard Workloads based on rates

The formula for calculating Standard Workloads based on a rate for an activity is:
Standard Workload = rate x available time in the year
Example
If a health assistant (Category B) can inspect 10 commercial premises per day, then the
10/day x 234 days/year = 2,340 inspections/year
This does not mean that a health assistant would be expected to carry out 2,340 inspections every
year. These staff also undertake many other activities. Rather it means that each inspection takes
1/2,340th of a working year for a health assistant.
If a registered nurse (Category A) can deal with 35 outpatient attendances per day, then the
35/day x 222 days/year = 7,770 outpatient attendances a year
This does not mean that a nurse in the outpatient department would be expected to treat 7,770
outpatients every year. These staff also undertake many other activities. Rather it means that each
outpatient treated will take 1/7,770th of a working year for such a nurse.
Allowance Factors
There are two types of Allowance Factor:
a) Those which apply to all staff in a particular category, however many are employed in a
facility, e.g. one hour per day cleaning up by all pharmaceutical assistants employed in a
dispensary; all hospital doctors employed in a department attend clinical meetings for 5.5
hours per week. This is a Category Allowance Factor.
58 _________________________________________________________________________________________
b) Those Allowance Factors which apply to a fixed number of staff in a particular category,
however many are employed in a facility, e.g. two pharmaceutical assistants undertake stock
unloading and storage which occupies them for two days per month; one doctor in each
hospital department produces notes of the clinical meetings, which occupies four hours per
week. This is an Individual Allowance Factor (so called because it originally applied to
single individuals in a working situation, although it can apply to any fixed or specified
number of staff).
Category Allowance Factors

All category Allowance Factors are converted into percentages. All the separate allowances for
a particular staff category working in a particular type of health facility are totalled before being
used to calculate the Staffing Requirements for the category.
Examples
An allowance of 10% for administration is already in the required form of a percentage.
An allowance of one hour per day for all pharmaceutical assistants undertaking cleaning in
dispensaries is equivalent to:
1 hour/day
= 12.5%
8 hours/day
In another country, where the normal working day is six hours, an allowance of one hour per day
would be equivalent to:
1 hour/day
= 16.7%
6 hours/day
An allowance of two days per month for all staff (including pharmaceutical assistants) to collect
their salaries is equivalent to:
2 days/month x 12 = 24 days/year
24 days/year
= 10.3%
234 days/year
The total category Allowance Factor for pharmaceutical assistants (daily cleaning + monthly
collection of salaries) is:
12.5% + 10.3% = 22.8%
An allowance of five hours per week for clinical meetings of medical staff in a hospital is
equivalent to:
_________________________________________________________________________________________ 59
5 hours/week
= 11.4%
44 hours/week
If all the hospital doctors spend a further 10% of their time on administration, the total category
Allowance Factor for these doctors would be:
11.4% + 10% = 21.4%
The use of these total category Allowance Factors in the calculations requires the application of
a further mathematical formula. The form of the Allowance Standards which the expert groups
estimate, i.e. actual time or percentage time taken, is designed to make it as easy as possible for
these groups to accomplish their task. However, in order to use these figures in the WISN
calculations a further arithmetical stage required. The complete procedure is:
a) Category Allowance Standards which are specified in terms of actual time (hours/day,
days/week, etc.) are converted to percentages;
b) All the percentage allowances for a particular staff category working in a particular type of
health facility are added together;
c) The allowance Multiplier to use in the WISN calculation for the staff category in the type
of health facility is computed using the total % category allowance from (b) according to the
formula:
1
Allowance multiplier =
total % category allowance
1-
100
The computer can be programmed to calculate this multiplier from the list of category Allowance
Standards for a staff category and then automatically include it in the calculations.
Individual allowance factors

An Individual Allowance Factor indicates the need for a fixed extra Staffing Requirement rather
than for a multiplier which is applied to the whole of the calculated requirement for a staff category
in a health facility. For example, a task requiring four hours per week of one doctor's time
throughout the year takes up 4 x 52 = 208 hours per year. The doctor is in Category A (1,776 hours
per year available working time) and so the task requires:
208 / 1,776 = 0.12 whole time equivalent
This fixed amount is added to the total calculated requirement for medical staff in those facilities
where this task is performed.
If two pharmaceutical assistants are required to undertake a task for two days per month, the annual
workload of the task is:
60 _________________________________________________________________________________________
2 staff x 2 days/month x 12 months = 48 days/year
These staff are in Category B (234 days per year available working time) and so the task requires
48 / 234 = 0.21 whole time equivalent
This fixed amount is added to the total calculated requirement for pharmaceutical assistants in
those facilities where this task is performed.
4. Using standard workloads and allowance standards to calculate staffing

requirements
The calculation of the Staffing Requirements for a staff category employed in any health facility
is performed according to the following steps:
1. For each component of workload (main activity) which has a Standard Workload i.e. it is
related to an item in the service statistics, apply the Standard Workload to the most recent
annual service statistics from the facility in order to calculate the Staffing Requirement for
each of these components of workload.
2. Add together the calculated Staffing Requirements for all these components of workload.
3. Calculate the Allowance Multiplier based on the category Allowance Standards.
4. Apply the Allowance Multiplier from step 3 to the total from step 2.
5. Add the Staffing Requirement for any Individual Allowance Factors which apply.
The steps in the complete calculation of the Staffing Requirements (SR) for each staff category can
be set out on a pro forma for manual calculation or they can be programmed into a spreadsheet.
They are as follows:
Volume of activity 1 in a year (from annual statistics) / Standard Workload for activity 1 = [SR1]
Volume of activity 2 in a year (from annual statistics) / Standard Workload for activity 2 = [SR2]
.....
.....
Sub-total [SR(Sub)]
Category Allowance Standard 1 = [CAS1] %
Category Allowance Standard 2 = [CAS2] %
.....
.....
Category Allowance Factor [CAF] %
Allowance Multiplier derived by formula from [CAF]: x [AM]
Intermediate Staffing Requirement [ISR]
Individual Allowance 1 = [IA1] WTE
Individual Allowance 2 = [IA2] WTE
.....
_________________________________________________________________________________________ 61
.....
Total Individual Allowance [IA total] + [IA total]
Calculated Staffing Requirement [CSR]
62 _________________________________________________________________________________________
Examples
a) Calculating the number of school dental therapists required in a district
Components of Workload: Activity Standards Standard Workload

School dental screening 1 screening/day 234/year
Administration, all staff 10%
Workload last year:

Number of school dental screenings last year = 648
Calculation:
648 screenings / 234 = 2.77
Category Allowance Factor = 10%
Allowance Multiplier = 1 / (1 - 0.1) = 1.11
INTERMEDIATE Staffing Requirement = 2.77 x 1.11 = 3.07 staff
No Individual Allowance Factors
CALCULATED Staffing Requirement = 3.07 school dental therapists
The district requires three school dental therapists to maintain the current level of school screening
achieved.
b) Calculating the number of community health workers (CHW) required in a health post

Outpatients 10 mins/patient 11,232 pats/yr
Home visits 12 mins/visit 9,360 homes/yr
Category Allowance Standard

Travelling 1.5 hours/day 18.75%
Individual Allowance Standard

Administration, 1 CHW 15% 15%
Workload last year:

Outpatients 15,381
Home visits 7,437
Calculation:
_________________________________________________________________________________________ 63
15,381 outpatients / 11,232 1.37

=
7,637 home visits / 9,360 0.82

=
Sub-total 2.19
Category allowance = 18.75%

Individual Allowance Factor: 0.15 x 52 weeks x 5.5 days/week

= 43 days/yr spent on administration
= 43 / 234 = 0.18 staff
CALCULATED Staffing Requirement = 2.69 + 0.18 = 2.87 staff
The health post requires three community health workers for the volume of service it delivers.
c) Calculating the number of medical records officers required in a hospital

Outpatient registration 3 mins/patient 37,440
Inpatient admission 10 mins/patient 11,232
Inpatient discharge 5 mins/patient 22,464
Category Allowance Standards

Shelving returned files 0.5 hours/day 6.25%
Compiling daily data 0.5 hours/day 6.25%
Category Allowance Factor 12.5%
Individual Allowance Factors

Compiling patient data, 1 person 2 days/month
Administration, 1 individual 10%
Workload last year:

Outpatients 25,319
Inpatient admissions 2,817
Inpatient discharges 2,674
Calculation:
64 _________________________________________________________________________________________
25,319 outpatients / 37,440 0.68

=
2,817 admissions / 11,232 0.25

=
2,674 discharges / 22,464 0.12

=
Sub-total 1.05
Category Allowance Factor = 12.5%
_________________________________________________________________________________________ 65
Individual Allowance Standards:
2 days/month x 12 = 24 days/yr spent on compiling data

= 24 / 234 working days/yr = 0.10 staff
0.1 x 52 weeks x 5.5 days/week = 29 days/yr on administration
= 29 / 234 working days/yr = 0.12 staff
Individual Allowance Factor = 0.10 + 0.12 = 0.22 staff
CALCULATED Staffing Requirement = 1.20 + 0.22 = 1.42 staff
One medical records officer would be 42% overloaded in this situation. Two staff will be required,
and these would be sufficient to cope with a 40-50% expansion of the hospital's workload. Other
things being equal, this would be an excellent place to post a new and inexperienced medical
records officer as an assistant or apprentice where there would be plenty of time for supervision.
Alternatively, if local circumstance permit, the figure would justify employing one part-time staff
(half time) under the supervision of one full- time staff.
Fractional results
When the calculated Staffing Requirement comes at or near a whole number of staff, as in
examples (a) and (b) above, rounding off to give a practical figure for the staff requirement is no
problem. However, when the calculated Staffing Requirement shows a substantial fraction, as in
example (c), some explicit rounding off rule must be adopted. Rounding down to the next whole
number produces a calculated Staffing Requirement slightly less than the workload actually
indicates; rounding up produces a figure for staffing slightly greater than the workload actually
indicates. One principle which has been used is to round down by amounts of 10% or less for
figures of five or less. This is based on the view that staff should be expected to carry a 10%
overload in their work if necessary. This results in the following rule:
1.0 - 1.1 is rounded down to 1; 1.1 - 1.9 is rounded up to 2

For all larger numbers, fractions are rounded in the usual way i.e. up or down to the nearest whole
number, as is done for 5.1 - 5.9 in the table. This rounding procedure can be done automatically
by a computer before printing tables of results.
In the smallest health facilities, particularly in sparsely populated areas, the workloads are small
to the point of being insufficient to keep even one member of staff occupied full time. In these
situations the calculated Staffing Requirement is less than 1.0 and special considerations apply. The
choice here is between rounding up to 1, where the staff member would be under utilized, or
rounding down to 0 and in effect stopping the service which this category of staff provides and
perhaps even closing the facility. This is not a technical matter but rather an administrative
decision, which presumably would take into account the financial costs of maintaining a
underutilised service, achieving national targets of coverage of services, access to alternative
facilities, etc.
66 _________________________________________________________________________________________
Overlapping staff categories

Sometimes one calculation covers two or more staff categories at the same time, because the main
functions of these categories overlap and the workloads undertaken by each category are not
reported separately in the service statistics. For example, in many countries the medical assistant
or equivalent who is the person in charge at the health centre joins other staff e.g. rural medical
assistants, to deal with outpatients when other duties permit; naturally these outpatients are not
listed separately in the annual statistics but are reported as part of the total workload of the health
centre. Again, in many hospitals the in-charge in the technical support departments (laboratories,
X-ray, dispensary, physiotherapy, occupational therapy) spends some time on management and
administration (for which Individual Allowance Standards are set) and the remainder on the main
task of the department (performing tests, taking X-rays, filling prescriptions, etc.) along with the
other staff in the department. In these situations it is usual to calculate the total Staffing
Requirement for the department, based on reported workloads and Allowance Factors. This total
Staffing Requirement is subsequently divided between the individual staff categories employed e.g.
7 staff required in a hospital X-ray department according to WISN

calculations = 1 senior radiographer + 6 radiographers
5 staff required in a health centre dispensary according to WISN

calculations = 1 pharmaceutical assistant + 4 dispensers
This principle can also be used to apply a predetermined balance between two or more staff
categories. For example, it is possible to calculate the total ward nursing staff required in a hospital
and then to divide this total between different nursing categories according to a national policy for
ward staffing. Or if, in the example above, there were a national policy to employ equal numbers
of radiographers and radiographic assistants in hospital X-ray departments, then the calculated
Staffing Requirement would be:
7 staff required in a hospital x-ray department according to WISN
calculations = 1 senior radiographer

+ 3 radiographers
+ 3 radiographic assistants
These predetermined factors (one person in charge + remaining staff, fixed ratios between staff
categories, etc.) can easily be included in the spreadsheet formulae so that a computer would print
out the results as shown above.
5. Computerization of the WISN calculations

This section sets out the principles and main guidelines which should be followed in designing and
implementing the computerization of the WISN calculations; it does not seek to be a mini-textbook
of computer operations. Each implementation of the WISN Method will require access to a
computer, for short working sessions spread over a period of some weeks during set-up and
implementation, and subsequently for a relatively short period once a year (when the annual service
statistics become available). Each implementation will also require the services of a computer
operator who is familiar with the operation of a spreadsheet programme e.g. Lotus 123, Quattro,
Supercalc. This operator will be able to follow these principles and guidelines in order to set up
the computer so that:
_________________________________________________________________________________________ 67
a) Service statistics for individual health facilities are entered into the computer. A pro forma
is shown on the computer screen specifying the data items to be entered;
b) The computer automatically performs the WISN calculations;
c) The computer automatically prints out tables of results showing individual health facility
Staffing Requirements, district summaries, regional summaries, and national summaries as
required.
No special computer programming is required; the standard commands in any generally available
spreadsheet package are sufficient for the purpose. If the data collection, input, calculations and
printing of results are centralized in this way, it throws on to the centre the responsibility for the
prompt feedback of results, when they are produced, to the regional and district levels.
If a country has computerized its health service statistics, whether on a spreadsheet or database
package, much of the work in computerizing the WISN Method is already done. The calculations
and print-outs of WISN results could be an additional procedure carried out on the health statistics
already held in the computer i.e. a procedure additional to the annual compilation of individual
facility statistics and their consolidation into district, regional and national summaries which are
already performed. In this case the WISN calculations are a sub-routine in the programme for the
annual compilation of service statistics.
a) Data entry
For calculating the requirements of each staff category, the data items to be entered from the
service statistics are those specified in the Activity Standards which have been set for each of the
staff categories. For each type of health facility the task force should:
a) List all the staff categories employed in this type of facility;

b) List the Activity Standards set for each of these staff categories;
c) List the data items required by each of these Activity Standards;
This should already have been done by the groups setting the Activity Standards.
In some cases a data item is used for the calculations of the staff categories in one cadre only e.g.
laboratory tests for laboratory staff, X-ray examinations for X-ray staff, physiotherapy patients or
sessions for physiotherapy staff, etc. In other cases a single data item is used in the calculations
of the Staffing Requirements for several categories, perhaps in different cadres e.g. the average
number of inpatients or bed occupancy for calculating the Staffing Requirements of several
categories of hospital doctors, several categories of nurses, kitchen staff, laundry staff; the annual
number of outpatients for the calculations of several categories of doctors, several categories of
nurses, medical records staff, several categories of pharmacy staff, etc. in hospitals and health
centres. Therefore:
d) Consolidate these lists of data items in order to produce a comprehensive master list of the
data items from each type of health facility required by the WISN calculations.
These are the data items which must be entered into the computer for each health facility.
68 _________________________________________________________________________________________
It would be possible to set up a separate spreadsheet for the WISN calculations for each cadre i.e.
each with its own input format, data entry, calculations and table of results. Perhaps this is how
it would be arranged if the task were to be done manually in order to avoid the complexity and the
possibility of errors when dealing with calculations covering several cadres based on the same set
of input data. However, the computer is designed to handle this type of complexity with ease.
Also separate spreadsheets for each cadre would entail duplication of data entry, which can be a
considerable workload. The best approach is to have a single consolidated pro forma for the data
entry for each type of health facility which covers all the data items required for the WISN
calculations for all the staff categories employed in these health facilities. The computer itself will
select from this format the appropriate data items for each calculation, and insert the results into
the appropriate place in a comprehensive table of results.
It is usual to provide space in the data entry format for the figures for each month or quarter
(depending on the frequency of reporting in the country), so that a correction can be made for the
common situation in which some of the monthly or quarterly figures are missing for some health
facilities.
Data Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec No. of Estimated
item months annual
reports figure
If some individual entries are missing, the spreadsheet is set up to make a pro rata adjustment in
order to calculate best estimates of annual figures which are required by the WISN Method. The
estimated annual figure is given by the formula:
Sum of available entries x 12

Annual figure =
Number of available entries
The final column of this spreadsheet, Estimated Annual Figure, is the starting point of the WISN
calculations themselves.
Where only annual figures are available, they are entered directly into the "annual figure" column
of the data entry format, ignoring all the other entry columns. In these circumstances it is not
possible to make any correction for missing monthly figures or other imperfections which these
annual figures may contain.
The current staffing of each facility is also entered into the computer, since this is part of the WISN
calculation. The staff categories employed in the facility are listed below the service statistics
items in the final column of the spreadsheet as part of the starting point of the WISN calculation
for each facility.
Each type of health facility employs its own set of staff categories with their own Activity
Standards, and therefore each type of health facility has its own set of data items (service statistics
and staff categories) and data entry format. A separate data entry format must be produced for each
type of health facility covered by the WISN calculations. Thus there will be a health post data
entry format, a health centre data entry format, a district hospital data entry format, etc. Each
health post and health centre format is copied several times in one spreadsheet to provide enough
data entry tableaux for all the health posts and health centres in one district. When the data has
been entered and checked, the spreadsheet is saved as a file of the basic data for the WISN
_________________________________________________________________________________________ 69
calculations for one type of health facility in one district. Many such files can be saved on to one
diskette, and this provides the basic data for all health facilities in a district, a region or the whole
country.
When the data entry has been completed for a number of health facilities, the data file in the
computer memory represents a considerable investment in time and effort in collecting, entering
and checking the data. It is prudent to protect this investment. One way of doing this is to treat
the spreadsheet containing the data on a set of health facilities as an interim product of the
calculation process. When the data entry is completed the file is saved on to a diskette which is
then made "read only". The final column of this spreadsheet is copied to become the first column
of a second spreadsheet, the staffing calculation, which performs the WISN calculations for all
these health facilities and tabulates the results. Thus each type of health facility has a data file and
a calculation file stored on separate diskettes. The final column of each data file is copied to
become the first column of the corresponding calculation file.
b) WISN calculations
The computer is programmed to perform calculations of the type shown in the examples set out in
Section C.4 above. The data entry format for one type of health facility e.g. health centres, is used
for all facilities of that type throughout the country. Also the mathematical formulae for calcul-
ating Staffing Requirements for each cadre is the same for all health facilities of the same type
throughout the country. Thus these formulae (which may be complex) need be entered into a
calculation file in the computer only once and then copied to provide a separate calculation for each
health facility.
c) Tables of results
The result of the WISN calculations for each staff category in each health facility consists of four
items:
Actual staff: part of the data entry for each facility
Required staff: according to the WISN calculations
Difference: actual staff - required staff
Ratio (WISN): actual staff / required staff.
These four items are automatically inserted into preprogrammed tables of results. These tables
normally show the results for each staff category in a group of facilities e.g. all the health posts in
an area, all the health centres in a district, all the MCH clinics in a district, all the district hospitals
in a region, etc., for easy comparison between different facilities and between different staff
categories within a facility. A simple example of such results is shown in Section A.7, Table 2.
Such tables of results (covering one type of health facility) also shows the totals or averages for
each staff category employed in the group of facilities:
Actual staff: total for all facilities listed in the table
Required staff: total for all facilities listed in the table
Difference: net shortage or excess of staff in the group
Ratio (WISN): average ratio throughout the group.
These will be totals or averages for an area, district, etc. Another table must be programmed which
assembles these total/average figures for all the areas in a district in order to produce district totals
and averages, for all the districts in a region to produce the regional totals and averages, etc.
70 _________________________________________________________________________________________
Annex A - Staffing requirements for time-specified posts

It is instructive to use the calculated available working time per year for different staff categories
in order to make a few illustrative calculations of the staffing resources required in a number of
special situations. In all these situations the Staffing Requirement is not determined by the
workload of a post; rather they are the staffing resources required to man a post for a specified time
pattern during the year. Each calculation uses the figures from Section C.1 example 2:
a) Manning a post during normal working hours throughout the year i.e. not on weekends,
public holidays, etc.
This is required in many posts e.g. in day clinics, district and provincial offices, MOH.
The total time for which the post is manned during the year is:
52 weeks x 44 hours/week - 10 public holidays x 8 hours/day
= 2,288 - 80 = 2,208 hours/year
One staff in Category A is available 1,776 hours/year, so the post would require
2,208/1,776 = 1.24 staff of Category A
In other words, if this is a Category A post, manning it on normal working days throughout the year
requires one full time staff in Category A and another 0.24 or 24% of a similar staff member's time,
in order to cover for vacation, training, sickness and all other absences. Manning 4 of these posts
would require 4 x 1.24 = 4.96 , i.e., 5 staff to be employed.
One staff of Category B is available 1,872 hours/year, so the same type of post would require
2,208/1,872 = 1.18 staff of Category B
In other words, if this is a Category B post, manning it on normal working days throughout the year
requires one full time staff in Category B and another 0.18 or 18% of a similar staff member's time,
in order to cover for vacation, training, sickness and all other absences. Manning five of these
posts would require 5 x 1.18 = 5.90 i.e. 6 staff to be employed.
b) Manning a post 8 hours/day, 7 days/week throughout the year

This is required for some posts in support departments in major hospitals e.g. maintenance staff.
52 weeks x 7 days/week x 8 hours/day = 2,912 hours/year
One staff in Category A, e.g. senior engineer, is available 1,776 hours/year, so the post would
require
In other words, if this is a Category A post, manning it on day shifts throughout the year requires
one full time staff in Category A and another 0.64 of a similar staff member's time, in order to
cover not only for vacation, training and sickness as before, but also now for weekends and public
holidays as well. Manning one such post in a facility would require employing two staff, but three
of these posts (in a much larger facility) would require 3 x 1.64 = 4.92, i.e. only five staff to be
employed.
One staff of Category B, e.g. maintenance engineer, is available 1,872 hours/year, so the post
would require
_________________________________________________________________________________________ 71
In other words, if this is a Category B post, manning it on days throughout the year requires one
full time staff in Category B and another 0.56 of a similar staff member's time, in order to cover
not only for vacation, training and sickness as before, but also now for weekends and public
holidays as well. Manning two of these posts would require 2 x 1.56 = 3.12, i.e. three staff to be
employed.
c) Manning a post 8 a.m. to 10 p.m. six days a week and 8 a.m. to 6 p.m. on Sundays
These are the dispensary opening hours in the main hospitals in one country.
52 weeks x 6 days/week x 14 hours/day + 52 days x 10 hours/day
= 4368 hours/year + 520 hours/year = 4,888 hours/year
One staff in Category A e.g. pharmacist, is available 1,776 hours/year, so a Category A post in such
a dispensary would require
In other words, manning a Category A post in this dispensary requires employing 3 full time staff
in Category A. These staff would operate a shift rota to keep the post manned.
One staff of Category B is available 1,872 hours/year, so the post would require
In other words, manning each Category B post in this dispensary requires employing two full time
staff in Category B and finding another 0.61 of a similar staff member's time. These staff would
operate a shift rota to keep the post manned.
d) Manning a post continuously throughout the year

There are many such posts in hospitals e.g. ward nurses.
52 weeks x 7 days/week x 24 hours/day = 8,736 hours/year
One staff in Category A is available 1,776 hours/year, so the post would require
In other words, manning a Category A post continuously requires employing about five full time
staff in Category A to cover the continuous shift working, weekends and public holidays, and the
vacation, training and absence time of all the staff involved.
One staff of Category B is available 1,872 hours/year, so the post would require
In other words, manning a Category B post continuously also requires employing five full time
staff in Category B.
Of course, only a few posts in hospitals are manned continuously for three shifts; some are manned
for two shifts, and many for the day shift only. Even where there is continuous operation e.g. on
the wards or in the outpatient department (accident and emergency), there is differential manning
on the three shifts, with the fewest staff on duty during the night.
72 _________________________________________________________________________________________
Annex B – Instructions for groups which are setting activity standards

These are the instructions for a cadre group, i.e. a group of senior and experienced staff in a cadre
who will set the Activity Standards for all the staff categories within the cadre in all of the health
facilities in which these categories are employed. The instructions also apply with very little
adjustment to a facility group i.e. a group of staff from one type of health facility who will set the
Activity Standards for all the staff categories which are employed in this type of facility. These
adjustments are all noted in the text.
1. List all the types of health facility which are to be covered. [For a facility group the type of
health facility is already determined and they list all the departments/units within the facility
which are to be covered by the exercise.]
2. Select one type of facility [department/unit]. List all the staff categories which have
established posts in this type of facility [department/unit] i.e. all the staff categories which
should be employed in them. [A cadre group will list only the staff categories within its own
cadre employed in each type of facility. A facility group will list all staff categories
employed in each department/unit.]
3. For each of these staff categories in turn, list the major activities which these staff undertake
in the work of the facility. The major activities are those which together take up all or
virtually all of the working time of the staff category in the health facility [department/unit].
These are called the components of workload for the job. For most staff categories there
are not more than four of these components of workload; some staff categories have only
one or two. If necessary combine some related activities into one component of workload.
[Using job descriptions to identify the components of workload of a staff category is usually
not helpful; job descriptions are frequently out of date and in any case are too detailed for
this purpose. It is better for those with direct experience of the work in these facilities to
suggest from their own experience the major activities undertaken there by each staff
category.]
4. Take the first category of staff and identify which of the components of workload are
covered by items in the statistics which are regularly collected and reported in these
facilities, and also which of the components of workload are not covered by these statistics.
If none of the data items in the reported statistics are directly relevant to one of the
components of workload, try to find a proxy measure of the workload e.g. number of
outpatient attendances instead of prescriptions filled, for the workload of hospital dispensers;
number of hospital admissions instead of bed occupancy, for ward staff; number of
inpatients instead of items washed, for the workload of launderers.5. For each of the
components of workload which are covered by an item in the statistics, specify what the
item is e.g. outpatient visits, antenatal examinations, inspections of premises, etc. and set a
unit time for it e.g. 10 mins for an outpatient visit, 20 mins per antenatal examination, or set
a rate for the activity e.g. 10 inspections/day.
This is the most critical step in the whole task. These unit times or rates should correspond to the
standard of performance which would be expected of experienced and well motivated staff taking
into account the general situation or circumstances found in these facilities in the country e.g.
availability of equipment and supplies.
_________________________________________________________________________________________ 73
6. For the components of workload which are not covered by items in the statistics, set a time
allowance for each activity. This allowance may be in the form of a percentage e.g.
administration: 10% of total time. Alternatively it may be in the form of a time allowance
e.g. cleaning: one hour per day; clinical meetings: five hours per week; stocktaking and
replenishing two days per month. The allowance may apply to all staff in a category, e.g.
all doctors in a hospital attend clinical meetings, or it may apply only to a fixed number of
staff however many staff are employed e.g. one person in charge carries out the admin-
istration in the unit, or two staff perform the stocktaking and replenishment.
7. Now repeat steps 4-6 for each of the remaining staff categories listed in step 2 as being
employed in these facilities, using the list of components of workload for each of these
categories from step 3.
8. Is there a staff category with none of its major work activities covered by any item in the
annual service statistics e.g. cleaners, drivers? if there is, this category must be given a
different type of workload standard, which must be one of the following:
ratio on other staff e.g. one medical assistant per four rural medical aides in a health centre,
one laboratory assistant per two rural medical aides in a health centre;
fixed number per facility e.g. three watchmen per health centre, one nursing attendant per
dispensary;
fixed number per item e.g. one driver per vehicle, two radiographers per X-ray machine;
fixed number per administrative unit e.g. one health assistant per electoral ward;
staffing according to organizational structure e.g. one district health officer per district, one
regional pharmacist per region.
In these cases no separate allowances (for administration, supervision, etc.) are made; these factors
are already included in the workload standard.
9. Now estimate for each of the staff categories employed in the facility:
average number of days per year engaged in off-the-job training;
average number of days per year for sickness and other absence.
These figures are used in determining the working time available per year, see Section B.1.
10. Now repeat steps 2 to 9 for all the remaining types of facility [department/unit] listed in
step 1.
11. Make a table of the results as follows:
74 _________________________________________________________________________________________
Facility type 1
Staff category 1
Major activity 1 Statistics item Unit time or rate

Major activity 2 Statistics item Unit time or rate
………
Allowance 1 Number of staff (1, 2 .... all) % or hours per day/ week/month/etc.
Allowance 2 Number of staff (1, 2 .... all) % or hours per day/ week/month/etc.
………
Average off-the-job training time days per year
Average total absence, sickness etc. days per year
Staff category 2
etc.
Facility type 2
Staff category 1
etc.
_________________________________________________________________________________________ 75
76 _________________________________________________________________________________________
___________________________________________________ Section D – Examples of WISN activity standards already used for individual staff categories
Section D:
Examples of WISN activity standards already
used for individual staff categories
This section lists some of the activity standards which have been used in WISN calculations in
various countries. They are offered for guidance only. Each country must set its own activity
standards.
These activity standards offer two types of information:
- how the jobs of different staff categories have been broken down into their main functions and
tasks (components of workload) in order to set activity standards for each;
- what actual times or rates (activity standards) have been set for these functions and tasks.
There are no absolutely correct or incorrect activity standards for any of the staff categories. The
same job title may refer to two very different jobs in different countries. For example, in some
countries the community health nurse has six months training and is one of two staff in the smallest
type of local health facility operated by the government, whereas in other countries the same title
refers to a three-year trained nurse with a number of years' experience and a further one-year public
health qualification who is in charge of all public health nursing in a sub-district. The main
activities (and the corresponding components of workload) are quite different for these two
categories of staff. Even if the two jobs are the same in principle, their tasks may be very different
because of different medical practices in the countries. For example, in some countries the three-
year trained ward nurse carries out all tasks related to inpatients (clinical procedures, administering
medication, feeding, personal hygiene, etc.) whereas in other countries the three-year trained ward
nurse is a technical worker who only performs clinical procedures and issues medication (but does
not administer it), with the other patient-related tasks being performed by other categories of ward
staff. While the list of the components of workload may be nearly the same for the two staff
categories, the activity standards will be quite different.
For these reasons the examples which follow, which show what activity standards have been used
in other countries, are offered for guidance only. They show what components of workload have
been used for a number of staff categories, which may be more directly useful than the associated
unit times, rates, etc.
Country or territory
United Republic of Tanzania ...................................................................................................... 76
Papua New Guinea ..................................................................................................................... 89
Kenya .......................................................................................................................................... 94
Hong Kong.................................................................................................................................. 94
Oman .......................................................................................................................................... 95
Sri Lanka..................................................................................................................................... 95
_________________________________________________________________________________________ 77
United Republic of Tanzania

Performance standards for staff in dispensaries/health posts
Staff category Component of workload Unit time, allowance

Rural medical aide Outpatient care
First visit 15 mins
Subsequent visits 5 mins
Administrative duties 20% of working time
Collecting salary 3 days/month
MCH aide Antenatal examinations
First visit 30 mins/patient
Subsequent visits 15 mins/patient
Under-5 examinations
First visit 15 mins/child
Subsequent visits 10 mins/child
Family planning
First visit 30 mins/client
Subsequent visits 10 mins/client
Immunisations 7 mins/immun.
Supervised deliveries 5 hours/delivery
Home visits 2 hours/visit
Health education 15 mins/meeting
Cleaning 1 hr/weekday + 5 hrs on Saturday = 10 hrs/week
Supervision of TBA &VHW 10% of working time
School health 2 hrs/week
Nursing assistant Attending outpatients 30 patients/day
Cleaning 1 hr/day: 6 hrs/week
Health assistant Home inspections 10 homes/day
Food premises 5 premises/day
Disease control 1 day per outbreak
Administrative tasks 2 hrs/day
Nursing attendant Cleaning full-time Allow 1 per facility
Medical assistant Outpatients
Ward rounds ) 9 hrs/week
Medical/surgical procedures )
Administration, supervision, 4.5 hrs/day
public relations
Collection salary 3 days/month
Rural medical aide Outpatients
Ward rounds ) 3 hrs/day
78 _________________________________________________________________________________________

Medical/surgical procedures )
Nurse/midwife Outpatients 40 patients/day
Inpatients 1n/m per 20 inpatients
Administration 20% of working time
MCH aide Antenatal examinations
Under-5 examinations
First visit 15 mins/child
Subsequent visits 10 mins/child
Family planning
First visit 30 mins/client
Subsequent visits 10 mins/client
Immunisations 7 mins/immun.
Supervised deliveries 5 hours/delivery
Home visits 2 hours/visit
Cleaning 1 hr/weekday + 5 hrs on Saturday = 10 hrs/week
Supervision of TBA &VHW 10% of working time
School health 2 hrs/week
Nursing assistant Inpatients 1 NA per 10 inpatients
Health assistant Home inspections 10 homes/day
Food premises 5 premises/day
Disease control 1 day per outbreak
Administrative tasks 2 hrs/day
Laboratory assistant Haematology 25 mins/specimen
Bacteriology 30 mins/specimen
Parasitology 15 mins/specimen
Medical records assistant Registration of outpatients 120 patients/day
Maintaining records ) 1 hr/day
Compiling analyses )
Cooking staff Feeding inpatients 1 staff/12 inpatients
Laundry attendant Laundering 1 staff/12 inpatients
Nursing attendant Cleaning 1/10 beds
Driver Allow 1 driver per vehicle
Watchman Allow 3 per health centre
_________________________________________________________________________________________ 79
Performance standards for staff in hospitals

Doctors
Medical specialists, medical officers, assistant medical officers and medical assistants are
employed in regional and district hospitals. The components of workload which cover most
medical staff in most specialties and the measures of workload appropriate for each, were identified
to be:
Ward rounds, minutes per inpatient
Outpatient clinics, minutes per outpatient
Medical procedures following the ward rounds, hours per day
Postmortems, hours per pm (including writing the report)
Clinical meetings (daily and weekly), total hours per week
Administration (letters, meetings, etc.), hours per week
Outside service in major emergencies, e.g. epidemics, floods, etc., weeks per year
Research, person weeks per year.
Specialists are not employed in district hospitals and so no standards for them are shown in these
facilities. Standards are not shown for medical assistants in regional hospitals in accordance with
the national policy although it was recognized that this policy was not followed. This became
apparent in the results of the WISN exercise, when the calculated staffing requirements according
to the policy were compared with actual staffing in the hospitals.
The standards are based on one ward round in each ward per day; in regional hospitals the
standards allow for specialists' rounds twice a week in surgery and in obstetrics and gynaecology,
and three times a week in all other specialist departments. The clinical meetings nearly all follow
the same pattern - half an hour per day and a three-hour meeting once a week, total 5.5 hours/week.
a) General medicine
Regional hospital District hospital
SPEC MO AMO MO AMO MA
Wd rds, mins/pat 10 10 10 10 10 10
Procs, hrs/day 0.5 1 1 1 1 1.5
Outpts, mins/pat 5 8 8 8 8 6
Pstmtms, hrs/pm 2 2 2 2 2 0
Cln mtgs, hrs/wk 5.5 5.5 5.5 5.5 5.5 5.5
Admin, hrs/wk 3 3 3 3 3 0
Emy svce, wks/yr 1 1 1 1 1 0
Rsch, mwks/yr (1) 13 13 13 13 13 13
1
All doctors allowed three months research per year.
80 _________________________________________________________________________________________
b) Surgery
Wd rds, mins/pat 10 5 5 10 10 5
Procs, hrs/day major 2 2 2 2 2 0
minor 1/4 1/4 1/4 1/4 1/4 1/4
Outpts, mins/pat 10 8 8 10 10 10
Pstmtms, hrs/pm(1) 0 2 2 2 2 0
Cln mtgs, hrs/wk 5.5 5.5 5.5 5.5 5.5 5.5
Rsch, mwks/yr 4 2 1 4 2 1
1
Specialist does very few postmortems per year, no calculation made of this workload.
c) Paediatrics
Wd rds, mins/pat 10 8 8 8 8 8
Procs, hrs/day 3/wk 1 1 1 1 1
Outpts, mins/pat 10 10 10 10 10 10
Stmtms, hrs/pm 2 2 2 2 2 0
Cln mtgs, hrs/wk 5.5 5.5 5.5 5.5 5.5 5.5
Rsch, mwks/yr (1) 1.3 1.3 1.3 1.3 1.3 1.3
1
Research is undertaken by 10% of staff, each of whom are engaged on it for 13 weeks per year i.e. an
average of 1.3 weeks for all staff.
d) Obstetrics & gynaecology

Wd rds, spec mns/pt 20 20 20 - - -
ordy mns/pt - 15 15 15 15 0
Procs, hrs/day 4/wk 3 3 3 3 0
Outpts, mins/pat 15 15 15 15 15 0
Ptmtms, hrs/pm(1) 0 2 2 2 2 0
Cln mtgs, hrs/wk 5.5 5.5 5.5 5.5 5.5 5.5
Emy svce, wks/yr(2) 0 0 0 0 0 0
Rsch, mwks/yr (3) 8 for dept 8 for dept
1
Specialist does very few postmortems per year, no calculation made of this workload.
2
These staff not called out for emergency service.
3
Research undertaken by one doctor at a time in each hospital for two months per year.
_________________________________________________________________________________________ 81
e) Psychiatry
Regional hospital(1)
SPEC MO AMO MA
Wd rds, mins/pat 30 20 20 10
Procs, hrs/day 0.5 1 1 1
Outpts, mins/pat 30 20 20 10
Pstmtms, hrs/pm 2 2 2 0
Cln mtgs, hrs/wk(2) 8.5 8.5 8.5 8.5
Admin, hrs/wk 3 2 2 0
Emy svce, wks/yr 1 1 1 1
Rsch, mwks/yr (3) ---20 for dept---
1
No psychiatric medical staff in district hospitals.
2
Clinical meetings include an extra three-hour meeting per week.
3
Research undertaken by two staff at a time in each regional hospital for ten weeks per year.
f) Ophthalmology
Regional hospital(1)
SPEC AMO(2)
Wd rds, mins/pat 8 10
Procs, hrs major 0.5 0
minor 1/4 1/4
Outpts, mins/pat 15 10
Pstmtms, hrs/pm(3) - -
Cln mtgs, hrs/wk 5.5 5.5
Admin, hrs/wk 3 3
Emy svce, wks/yr 1 1
Rsch, mwks/yr(4) 4 for dept
Mobile clinics (5) 1 day travel per clinic
1
No ophthalmology medical staff in district hospitals.
2
Only eye specialist and AMOs employed in these departments.
3
Ophthalmology staff do not undertake postmortems.
4
One member of staff in the department undertakes research for four weeks per year.
5
Mobile clinics require one day for travelling; patient contact time already allowed for under other items.
g) Public health
There should be one public health doctor for each district and one for the region, whose annual
time allocation should be:
Dealing with epidemics 6 weeks/year

Health education 12 weeks/year
Endemic diseases 15%
Administration 35%
Research 20%
82 _________________________________________________________________________________________
h) Anaesthesiology
Regional hospital District hospital(1)
SPEC MO MA MO MA
Wd rds, mins/pat 10 10 10 - -
Procs, hrs major(4) 3.75 3.75 0 3.75 3.75
minor(4) 0.5 0.5 0 0.5 0.5
Other hrs/wk 2 2 0 - -
Outpts, mins/pat(2) - - - - -
Pstmtms, hrs/pm(2) - - - - -
Cln mtgs, hrs/wk 5.5 5.5 5.5 5.5 5.5
Admin, hrs/wk 3 3 2 -
Emy svce, wks/yr(2) - - - -
Rsch, mwks/yr (3) 5 for dept - -
1
District hospital requires one anaesthetic officer + medical assistants sufficient to cover the workload.
2.
Anaesthetic staff do not undertake outpatient clinics, post mortems or outside work in major emergencies.
3.
One member of staff in the department undertakes research for five weeks per year.
4.
Staff time required on average for operations is as follows:
Major Minor
Pre-op examination 15 mins )
Preparing equipment 10 mins ) 5 mins
Pre-op medication, induction 5 mins )
Operation 2 hours 15 mins
Post-op monitoring 30 mins )
Cleaning equipment 15 mins ) 10 mins
Follow-up, 5 mins every 4hrs 30 mins )
for 24 hours, 6 x 5 mins
Totals 3hr 45 mins 30 mins
Nursing staff
Some Performance Standards for nurses were already covered by a Handbook of Nursing Practice
(or Standards). This specified the number of outpatients or clinic attendances per day per nurse,
and in general terms the number of occupied beds a nurse can supervise. The Performance
Standards for ward nurses, set out below, are much more detailed and specific.
The standards for the senior nurses were:
Matron One for each regional or district hospital

Asst. matron One for each regional or district hospital
Nursing officer One for up to 30 nursing staff employed in the ward, unit, etc.
Asst. nursing officer One for each further 30 nursing staff employed in the ward, unit, etc.
The Performance Standards for nurses, nurse midwives and nurse assistants who work on the wards
were based on inpatient ratios, i.e. the number of inpatients which a member of staff could
reasonably be expected to cover in performing their nursing functions during the shift. This
inpatient ratio was lower in regional hospitals (i.e. requiring more staff for the same number of
_________________________________________________________________________________________ 83
inpatients) where the more serious cases are treated by specialists. The ratio varied with the shift;
fewer nurses were needed on the wards at night. Where a variation between shifts is specified, it
is allowed for in the calculation of staff need. This ratio also differed for different types of nursing,
e.g. paediatric, psychiatric, etc., and these ratios were estimated because bed occupancy figures for
each ward were available in the service statistics. The workload standards for nurse attendants,
whose task is mainly cleaning, were based on the number of beds in the ward (as a proxy for size)
not the number of inpatients (occupied beds); they also show variation by type of hospital and by
shift.
The mathematical formula for calculating the number of nurses needed to staff a ward with specific
inpatient ratios is as follows:
Morning shift: A hours long, ratio 1 nurse to K inpatients

Afternoon shift: B hours long, ratio 1 nurse to L inpatients
Night shift: C hours long, ratio 1 nurse to M inpatients
Nurses required/ 365
inpatient (occupied bed) = x (A/K + B/L + C/M)
AWT
where AWT = Available Working Time in hours per year
Exactly the same formula is used to calculate the number of nurse attendants required. In this case
K, L and M are the number of beds in each ward instead of the average number of inpatients.
The shift rota in the hospitals was 7-2, 2-8 and 8-7 i.e. 7 hours/6 hours/11 hours, and so in the
formula:
A=7
B=6
C = 11
The values of K, L and M in different situations are given in the tables below.
In the tables ips = inpatients; bds = beds
a) General medical wards

District hospitals : Regional hospitals
Category / shift 7-2 2-8 8-7 : 7-2 2-8 8-7
NM/Trnd Nse 1/10 ips 1/10 ips 1/20 ips : 1/5 ips 1/5 ips 1/10 ips
Nse Asst 1/5 ips 1/10 ips 1/20 ips : 1/5 ips 1/10 ips 1/20 ips
Nse Attdt 1/10 bds 1/20 bds 1/20 bds : 1/10 bds 1/20 bds 1/20 bds
b) Paediatric wards
Category / shift 7-2 2-8 8-7 : 7-2 2-8 8-7
Nse Attdt 3/20 bds 1/20 bds 1/20 bds : 3/20 bds 1/20 bds 1/20 bds
84 _________________________________________________________________________________________
c) Psychiatric wards
Category / shift 7-2 2-8 8-7 : 7-2 2-8 8-7
NO Curative 1/5 ips 1/10 ips 1/20 ips : 1/5 ips 1/10 ips 1/20 ips
NO Community 1/5 ips - - : 1/4 ips - -
N0 Occ Therapy 1/10 bds - - : 1/10 bds - -
Nse Attd 1/10 bds 1/10 bds 1/20 bds : 1/10 bds 1/10 bds 1/20 bds
d) Maternity unit
Category / shift 7-2 2-8 8-7 : 7-2 2-8 8-7
NO ---------------------1 in charge + 1/10 deliveries/day --------------------
NM/Trnd Nse ------------------------ 4 hrs/delivery + 2 hrs/shift ------------------------
Nse Asst --------------------------------3 hrs/delivery --------------------------------
Nse Attd 1/10 bds 1/10 bds 1/20 bds : 1/10 bds 1/10 bds 1/20 bds
Patients admitted for antenatal care before delivery or for postnatal care afterwards are in the
general medical wards.
e) Operating theatres
Average duration of surgical operations:
General surgery Obst & gynae Ophthalmology

Major operations 2 hrs 2 hrs 30 mins
Minor operations 15 mins 15 mins 15 mins
General surgery and obs & gynae

Major operations: a team of 1 NO + 2 NMs + 4 nurse assistants for 30 mins
preparation + duration of operation + 30 mins clearing.
Minor operations: 1 NO or NM for 15 mins preparation + duration of operation + 15

mins clearing.
Ophthalmic surgery
All operations: 1 NO or ANO, preparation and clearing times as given above.
Nurse attendants, all types of surgery:

SHIFT
7-2 2-8 8-7
Regional hospitals 4 2 1
District hospitals 3 1 1
_________________________________________________________________________________________ 85
Nurses also staffed the regular outpatient clinics. These workload standards were set in terms of
the average number of minutes of nurse time occupied by each patient seen, or by the nursing team
required to be on duty throughout the clinic to support the doctor. In some of the older hospitals
these standards could not be met because of the restricted space available.
f) Ophthalmic clinic
Nursing officer and assistant nursing officer:
Screening 4 mins
Dispensing 4 mins
Eye investigations 5 mins
Admitting patients 8 mins
(on average 10% of patients are admitted)
Nursing officer: administration 3 hrs/week
Nurse assistant/attendant: 1/clinic
g) General medical clinic

Nurse midwife : 10 mins per patient
Nurse assistant : 1/clinic
Nurse attendant : 1/clinic
h) Psychiatric clinic
NO counselling : 2 hrs/patient, new and repeat cases; all others -
1 hr/new case, 15 mins/repeat case
Nurse midwife : 1/clinic
Nurse assistant : 1/clinic
Nurse attendant : 1/clinic
i) MCH clinic
1 PHN A for each clinic.
PHN B/nurse midwife: same workload standards as the MCH aide in health centres.
Nurse attendant: 3/clinic in regional hospitals; 2/clinic in district hospitals.
Hospital technical and support staff
a) Dental staff
Dental officer There should be one dental officer in each regional and district
hospital, spending 20% of the working time on preventive activities
and 10% on administrative activities
Assistant dental Owing to the shortage of dental officers, an assistant dental officer
officer could be appointed in the place of a dental officer
Dental technician Because there were so very few of this category in the country, and
their duties were covered by the dental officer, no workload standards
were proposed.
86 _________________________________________________________________________________________
Dental assistant School pupil screening and data analysis 1 day/school

Extractions 15 mins/extraction
Fillings 30 mins/filling
Scaling 1 hr/patient
Polishing 10 mins/patient
Admin. (supervision, reporting budgeting, 20%
salary)
Dental auxiliary Extractions 15 mins/extraction
Fillings 30 mins/filling
Scaling 1 hr/patient
Polishing 10 mins/patient
Cleaning and sterilisation 2 mins/pat + 1 hr/day
Salary collection 2 hrs/month
The dental auxiliary remains in close attendance on the dental assistant during patient treatment,
so has the same unit times for extractions, etc. Owing to the severe shortage of instruments, each
set is scrubbed and rinsed after use (two mins) and then sterilised; cleaning and sterilisation at the
end of the day takes one hour.
b) Pharmacy staff
Pharmacist There should be two pharmacists per regional hospital and one
pharmacist per district hospital. They undertake costing, ordering,
procurement, stores management (receipt and issue), compounding,
dispensing, clinical consultations, continuing education and
administration (meetings, reports, supervision, budgeting, etc.)
Pharmaceutical Dispensing 5 mins/patient
assistant Stores management 1.5 hrs/day
Administration 1 hr/day
Pharmaceutical Dispensing 5 mins/patient
auxiliary Salary collection 2 hrs/month
In addition, one hour's compounding was done each day by one of the above staff; it required one
hour of preparation and one hour of clearing, done by the pharmaceutical auxiliary.
Pharmaceutical Cleaning the rooms and equipment, loading and unloading

attendant pharmaceutical supplies and messenger duties require one
pharmaceutical attendant per four pharmaceutical assistants and
auxiliaries
c) Laboratory staff
Laboratory technologist Most advanced clinical chemistry: 30 mins/test
SGOT/SGPT, acid phosphates,
alkali phosphates, G6PD
Microbiology 45 mins/test
Immuno-serology: Elisa 1 hr/test
Trace transfusion reaction 2 hrs/test
L.E.test 30 mins/test
_________________________________________________________________________________________ 87
Bone marrow 30 mins/test

Administration (supervision, QA, 30%
meetings, supplies, etc.)
Laboratory technician Advanced clinical chemistry: uric 20 mins/test

acid, choloresterol, total protein,
albumen, bilirubin, amelase,
electrolytes
Histopathology: seminal fluid 5 mins/test
analysis, wet preparation, counts,
pap smear
Record keeping 1 hr/day

Laboratory assistant Specimen collection 5 mins/ specimen
Haematology: sickling test, 7 mins/test

haemoglobin test, ESR, PCV, WBC
(total and differential), bleeding
time, clotting time
Bacteriology: sputum - AFB, skin - 30 mins/test

AFB, gram stain
Parasitology: stool, urine, malaria 10 mins/test

parasites, skin snip.
Simple clinical chemistry:

Urine (sugar, protein) 5 mins/test
Blood (urea, sugar, createnim) 40 mins/test
Immunoserology: VDRL, HIV, 7.5 mins/test

pregnancy test, widal.
Blood donation: 42 mins/specimen

Cross matching, Coombs test.
Record keeping 1 hr/day

Laboratory attendant General cleaning and support, needs one laboratory attendant
per 3 laboratory assistants
88 _________________________________________________________________________________________
d) Radiography staff
Radiographer Preparation, positioning, operating 20 mins/patient
machine, evaluating, patient care.
Administration (management, 40%

stock, budgets, supervision,
meetings, etc.)
Radiographic assistant Skeletal examinations 20 mins/patient

Processing film 10 mins/film
Administration (registering, etc.) 25%
Radiographic attendant Cleaning the radiographic accommodation, allow one per

facility
e) Medical records staff

The unit times for the major activities were the same for both medical records officers and medical
records assistants:
Outpatient registration 3 mins/patient

Inpatient admission 10 mins/admission
Inpatient discharge 5 mins/discharge
Shelving files and register books 1 hr/day
Sorting files 3 mins/file
Compiling patient data 2 days/month
Administration 20%
f) Catering staff
Trained cook (head cook) Management, supervision, meetings, etc.
requires one trained cook per four cooks
Cook Cooking duties 1 cook/20 inpatients

Cleaning 2 hrs/day
g) Laundry staff
There were no staff categories in this cadre. The standard workloads were:
Regional hospital 1 laundryman/16 inpatients

District hospital 1 laundryman/30 inpatients
In addition, the person in charge at each facility spends 10% of time on administrative duties.
h) Hospital secretaries
The duties of a hospital secretary cover a very wide range of different types of activity, for most
of which statistics were not available. The factor which determined this workload was the number
of staff employed in the hospital and the standard workload was set at 250 staff, i.e. in a hospital
with more than 250 staff the hospital secretary should have an assistant hospital secretary for each
extra 250 staff employed by the hospital.
_________________________________________________________________________________________ 89
Outpatient department
Separate from the scheduled outpatient clinics, the outpatient department provided a service on
demand in dealing with casual illnesses and unspecified referrals. The person in charge should be
an MO in a regional hospital and an AMO in a district hospital. The workload standards for other
staff in the department were the same for both types of hospital. For a unit receiving 200
patients/day, the staffing required was:
SHIFT
Morning Afternoon Night
Medical assistant 4 2 2
Nursing officer 1 - -
Nurse midwives 4 2 1
Nursing assistants 8 4 2
Nurse attendants 2 2 1
Medical recorders 2 2 1
Staffing standards for other sizes of outpatient department are calculated pro rata.
90 _________________________________________________________________________________________
Papua New Guinea

Staff category Component of workload Activity standard
Consultant paediatricians Inpatients
in a teaching hospital Teaching rounds 3 hrs/round, 6 days/week
Business rounds 8 pats/hr, 365 days/yr
Patient care 1 hr/admission
Operative delivs. 30 mins/delivery
Postnatal ward 2.5 mins/delivery
Outpatients
General outpatients 5 attends./hour
Observation room 20/hr seen twice, 365 days/yr
Consultations 6 attends./hr
Ultrasound 2 staff do 2 in 12 hours
Outside visits 1 day/visit
Other activities
Teaching prep. 780 contact hrs/yr
Administration half day/week
Research half day/week
Consultant physicians in a teaching hospital

Consultant physicians Inpatients 3 hrs/round, 2 rounds/ week/unit

in a teaching hospital Teaching rounds
The specified teaching schedule requires one consultant, one registrar and one
resident on each teaching round.
Patient care rounds

General med. units 8 patients/hr, 6 days/wk
52 weeks/yr registrar + resident
TB unit 33 patients/hr, 6 days/wk

52 weeks/yr registrar + resident
Medical admissions Consultant 0.25 hr/adm.

Registrar 1 hr/adm.
Resident 2 hrs/adm.
Procedures in Gen. med. units 15 patients/hr, 6 days/week,

52 wks/yr registrar + resident
_________________________________________________________________________________________ 91
Outpatients
Gen. med. clinics 3/hour for all staff consultant,
registrar, resident
Specialty clinics:
Asthma, diabetes, cardiology 6/hr, each staff takes half the patients
consultant and registrar
Ultrasound 3/hr, each staff takes half the patients

consultant and registrar
Intermediate clinics 2/hr, consultants only
Outside visits
Hospitals Days spent consultants only
Health centres Days spent registrars only
Other activities
Teaching Consultant 780 hrs/yr
Administration Consultant half day/week

Registrar 1 hr/week
Research consultant half day/week

Registrar half day/week
Doctors in non-teaching hospitals

These workload standards cover both general medical officers and resident medical officers in non-
teaching hospitals.
Doctors in non-teaching Inpatients
hospitals Daily ward rounds 15 patients/hr i.e. admin. assistance from
nurses during rounds
Admissions 1 hr/MO admission

20 mins/HEO admission
proportion 50:50.
Procedures
Radiology 30 mins/patient
Lumbar puncture 15 mins/patient
Traction, plaster casts 30 mins/patient
92 _________________________________________________________________________________________

Operations All scheduled theatre time filled,
2 doctors for each operation
Outpatients
General 20 mins/patient
Clinics
Surgery 8 mins/patient
Medicine FV: 40 mins/patient
SV:15-20 mins/patient
Antenatal FV: 30 mins/patient
SV: 10 mins/patient
Gynae FV: 30 mins/patient
SV: 10 mins/patient
(FV = first visit, SV = subsequent visit)
Consultations, incl. interm'te 40 mins/patient
Other activities
Outside visits, supervision Days/yr spent on outside visits
by all doctors
Urban clinics Hrs/week for clinics throughout

the year
Clinical meetings hours/week for meetings attended

by all doctors
Research 2 hrs/week/doctor
Administration 12.5%
Health centres and sub-centres

Nursing officers Admissions 0.5hr/patient/day
Outpatients 50/day
Clinic attds. 670/month
Mobile attds. 500/month +travelling
Supervised births 12.5/month
Community health workers Admissions 1 hr/patient/day

Outpatients 30/day
Clinic attds. 2 CHWS to 3 nos
Mobile attds. 500/month +travelling
_________________________________________________________________________________________ 93
Aid posts
Community health workers Outpatients 22/half day + activities outside
the aid post
Urban clinics
Nursing officers Outpatients 50/day
Clinic attds. 670/month
Community health workers Outpatients 30/day
Hospitals
Nursing officers + Inpatients 2 hrs/patient/day
nursing auxs. Deliveries 9 hrs/delivery
Outpatients 44/day
The calculated total nurse staffing for hospitals is divided between nursing officers and nursing
auxiliaries after the WISN calculation.
Pharmacy staff
Pharmacists Advising specialists employed 0-1 speclsts: 0
in hospitals 2-7 speclsts: 1
8-20 speclsts: 2
21+ speclsts: 3
Dispensers Filling prescriptions 15/hr
Checking and replenishing Wards without imprest

ward orders replenished
Regular replenishment 3 times/week, 30 mins/order
Resetting imprest each imprest cleared annually,

1 week each
Regular stock check checked once a week

30 mins/check
Orders filled for other facils. 20 mins/aid post order

15 mins/hlth cntr order
Monthly stocktaking 20 mins/yr for each item stocked
94 _________________________________________________________________________________________

Replenishing first aid kits 10 mins/replenishment
in schools and govt. depts.
Making bulk supplies in Allow 0.25 staff

base hospitals only
Storemen Ward replenishment wards and clinics replenished 3

times/week, 2 hrs/ward or clinic
Receive supplies 40 mins/yr for each item stocked
Deliver medical gases 1.5 hours/delivery
Clerk/typist Type orders, maintain records 300 outpatient prescriptions/day
Pathology staff in base and Haematology 7 mins/test

provincial hospitals Biochemistry 9 mins/test
Microbiology 15 mins/test
VDRL 12 mins/test
Blood bank 21 mins/test
Supervision visits 1 day/visit
Research) 25%
Cleaning)
Clerical/ typing 12%
Management 7%
X-Ray staff in base and provincial hospitals

Radiographers Taking X-rays 15 mins/patient
Developing film manual: 200/day
machine:300/day
Scanning 3/hour
ECG 40 mins each
Clerical/typing 15 mins/patient
Nursing staff Specialist examinations 1 hour each
_________________________________________________________________________________________ 95
Kenya
Medical laboratory staff
The activity standard was set at 24 specimens per day for all types of tests. This standard allows
for the necessary time to be spent on cleaning, setting out, replenishing supplies, management,
recording and reporting, and all the other essential activities in a hospital laboratory which are not
recorded in the annual statistics but which must be done if the laboratory is to function effectively.
X-ray staff
The activity standard was set at 25 minutes per X-ray, 15 minutes for taking the X-ray and 10
minutes for developing.
Pharmacy staff
Province hospitals: one pharmaceutical technologist per five wards.
District and sub-district hospitals: one pharmaceutical technologist per 10 wards
Hong Kong
PHC and Public Health: direct service delivery activities

Registered nurse General outpatient 7 mins/attendance
Family health services

Child health 15 mins/attendance
Maternal health 15 mins/attendance
Family planning 5 mins/attendance
Comprehensive observation 23 mins/attendance
Clinical genetics 7.5 mins/attendance
Child assessment 1 hr 10 mins/assessmt.
TB & chest 17.5 mins/attendance
Social hygiene & special skin 45 mins/attendance
96 _________________________________________________________________________________________
Oman
Laboratory technician Haematology 2 mins/sample
Blood grouping 3 mins/sample
Biochemistry 3 mins/sample
Bacteriology
Culture 30 mins/sample
Other 10 mins/sample
Administration 15%
Sri Lanka
Consultants and supporting medical staff in teaching, province, base and district hospitals
Conslt SHO/MO/HO
Cancer surgery Inpatients
Admissions
Time per admission _ 15 mins
% seen _ 100%
Ward rounds
Time per inpatient 7 mins 8 mins
Procedures per round 60 mins 90 mins
Operations
Major operations
Time per operation 180 mins 180 mins
% performed 100%100%
Minor operations
% performed 40% 60%
Clinics
First visits
Time per FV 15 mins -
% seen 100% -
Subsequent visits
Time per SV - 7 mins
% seen - 100%
Teaching
Students, time per year 300 hrs
Postgraduates, time per year -
_________________________________________________________________________________________ 97

Conslt SHO/MO/HO
Cardiology Inpatients
Admissions
Time per admission 15 mins 20 mins
% seen 20% 80%
Ward rounds
Time per inpatient 4.5 mins 5 mins
Procedures per round - 45 mins
Operations
Major operations
Time per operation
% performed
Minor operations
Time per operation
% performed
Clinics
First visits
Time per FV 10 mins –
% seen 100% –
Subsequent visits
Time per SV 4 mins 5 mins
% seen 20% 80%
Teaching
Postgraduates, time per year –
Dermatology Inpatients
Admissions
Time per admission – 10 mins
% seen – 100%
Ward rounds
Procedures per round – 120 mins
Operations
Major operations
Time per operation
% performed
Minor operations
Time per operation
% performed
98 _________________________________________________________________________________________

Conslt SHO/MO/HO
Clinics
First visits
% seen 100% –
Subsequent visits
Time per SV 5 mins
% seen 20% 80%
Teaching
General surgery Inpatients

Admissions
% seen – 100%
Ward rounds
Operations
Major operations
% performed 100% 100%
Minor operations
% performed 20% 80%
Clinics
First visits
Time per FV 7.5 mins –
% seen 100% –
Subsequent visits
% seen 20% 80%
Teaching
Post graduates, time per year 75 hrs
Genito-urinary surgery Inpatients

Admissions
% seen – 100%
Ward rounds
_________________________________________________________________________________________ 99

Conslt SHO/MO/HO
Operations
Major operations
Minor operations
% performed 20% 80%
Clinics
First visits
% seen 100% –
Subsequent visits
% seen 20% 80%
Teaching
Postgraduates, time per year 75 hrs
Gynaecology Inpatients
% seen 20% 80%
Ward rounds
Operations
Major operations
Minor operations
% performed 20% 80%
Clinics
First visits
% seen 100% –
Subsequent visits
% seen 20% 80%
100 ________________________________________________________________________________________

Conslt SHO/MO/HO
Teaching
General medicine Inpatients

Admissions
% seen 10% 90%
Ward rounds
Operations
Major operations
Time per operation
% performed
Minor operations
Time per operation
% performed
Clinics
First visits
% seen 100% –
Subsequent visits
% seen 20% 80%
Teaching
Neurology Inpatients
Admissions
% seen 20% 80%
Ward rounds
Operations
Major operations
Time per operation
% performed
Minor operations
_________________________________________________________________________________________ 101

Conslt SHO/MO/HO
Time per operation
% performed
Clinics
First visits
% seen 100% –
Subsequent visits
% seen 10% 90%
Teaching
Neurosurgery Inpatients
Admissions
% seen 10% 90%
Ward rounds
Operations
Major operations
Minor operations
% performed 50% 50%
Clinics
First visits
% seen 100% –
Subsequent visits
% seen 10% 90%
Teaching
102 ________________________________________________________________________________________

Conslt SHO/MO/HO
Obstetrics Inpatients
Admissions
% seen – 100%
Ward rounds
Operations
Caesarian
% performed 80% 20%
Forceps delivery
% performed 40% 60%
Clinics
First visits
% seen 100% –
Subsequent visits
% seen 20% 80%
Teaching
Oncology Inpatients
Admissions
% seen – 100%
Ward rounds
Operations
Major operations
Time per operation
% performed
Minor operations
Time per operation
% performed
_________________________________________________________________________________________ 103

Conslt SHO/MO/HO
Clinics
First visits
% seen 100% –
Subsequent visits
Time per SV – 7 mins
% seen – 100%
Teaching
Ophthalmology Inpatients
Admissions
% seen 10% 90%
Ward rounds
Procedures per round – –
Operations
Major operations
% performed 90% 10%
Minor operations
% performed 20% 80%
Clinics
First visits
% seen 100% –
Subsequent visits 6 mins
Time per SV 6 mins
% seen 20% 80%
Teaching
Orthopaedic surgery Inpatients

Admissions
Time per admission – 12.5 mins
% seen – 100%
Ward rounds
104 ________________________________________________________________________________________

Conslt SHO/MO/HO
Operations
Major operations
Minor operations
% performed 20% 80%
Clinics
First visits
% seen 100% –
Subsequent visits
% seen 20% 80%
Teaching
Otolaryngology Inpatients
Admissions
% seen – 100%
Ward rounds
Operations
Major operations
Minor operations
% performed 20% 80%
Clinics
First visits
% seen 100% –
Subsequent visits
_________________________________________________________________________________________ 105

Conslt SHO/MO/HO
% seen 20% 80%
Teaching
Paediatric surgery Inpatients

Admissions
% seen – 100%
Ward rounds
Operations
Major operations
Minor operations
% performed 20% 80%
Clinics
First visits
% seen 100% –
Subsequent visits
% seen 20% 80%
Teaching
Paediatrics Inpatients
Admissions
% seen – 100%
Ward rounds
Operations
Major operations
Time per operation
106 ________________________________________________________________________________________

Conslt SHO/MO/HO
% performed
Minor operations
Time per operation
% performed
Clinics
First visits
% seen 100% –
Subsequent visits
% seen 20% 80%
Teaching
Plastic surgery Inpatients

Admissions
% seen 80% 20%
Ward rounds
Operations
Major operations
Minor operations
% performed 30% 70%
Clinics
First visits
% seen 100% –
Subsequent visits
% seen 20% 80%
Teaching
_________________________________________________________________________________________ 107

Conslt SHO/MO/HO
Psychiatry Inpatients
Admissions
% seen 30% 70%
Ward rounds
Operations
Major operations
Time per operation
% performed
Minor operations
Time per operation
% performed
Clinics
First visits
Time per FV 30 mins 30 mins
% seen 60% 40%
Subsequent visits
% seen 20% 80%
Teaching
Rheumatology & Inpatients

rehabilitation Admissions
% seen 80% 20%
Ward rounds
Operations
Major operations
Time per operation
% performed
Minor operations
Time per operation
% performed
108 ________________________________________________________________________________________

Conslt SHO/MO/HO
Clinics
First visits
% seen 100% –
Subsequent visits
% seen 20% 80%
Teaching
Thoracic surgery Inpatients

Admissions
% seen – 100%
Ward rounds
Operations
Major operations
Minor operations
% performed 95% 5%
Clinics
First visits
% seen 100% –
Subsequent visits
Time per SV 5 mins 7.5 mins
% seen 20% 80%
Teaching
Venereology Inpatients
Admissions
Time per admission
% seen
Ward rounds
_________________________________________________________________________________________ 109

Conslt SHO/MO/HO
Time per inpatient
Procedures per round
Operations
Major operations
Time per operation
% performed
Minor operations
Time per operation
% performed
Clinics
First visits
% seen 100% –
Subsequent visits
% seen 20% 80%
Teaching
Students, time per year ) 300 hrs
Postgraduates, time per year )
Medical staff in district hospitals with no consultants

Medical officers Inpatients 10 mins
Admissions
Time per admission 10 mins
% seen 100%
Ward rounds
Time per inpatient 6.25 mins
Procedures per round 20 mins
Clinics
First visits
Time per FV 10 mins
% seen 100%
Subsequent visits
Time per SV 5 mins
% seen 100%
Outpatients
Time per outpatient 5 mins
110 ________________________________________________________________________________________
Medical staff in peripheral units and rural hospitals

Medical officers Inpatient
Admissions
Time per admission 10 mins
% seen 100%
Ward rounds
Time per inpatient 4 mins
Procedures per round 20 mins
Clinics
First visits
Time per FV 10 mins
% seen 100%
Subsequent visits
Time per SV 6 mins
% seen 100%
Outpatients
Time per outpatient 5 mins
Teaching hospitals
Nursing staff Ward duty
Ward nurses Surgical 3 occ beds/nse
Medical 3 occ beds/nse
Paediatric 3 occ beds/nse
GYN/OBS 3 occ beds/nse
Neurosurgery 2 occ beds/nse
Orthopaedic 2 occ beds/nse
Psychiatric 4 occ beds/nse
Burns 2 occ beds/nse
Plastic surgery 2 occ beds/nse
Eye 5 occ beds/nse
ENT 5 occ beds/nse
Rheumy. & rehab. 6 occ beds/nse
Dermatology 6 occ beds/nse
Accident 6 occ beds/nse
ICU nurses ICU duty 5 nses/bed
Premature baby unit Prem. baby duty 5 nses/cot
_________________________________________________________________________________________ 111
Labour room Deliveries 4 nses/available bed

Clinic nurses Clinic duty
Medical 2 nses/clin
Psychiatric 2 nses/clin
Eye 3 nses/clin
ENT 3 nses/clin
Surgical 3 nses/clin
Skin 3 nses/clin
Orthopaedic 15 nses/clin
FP 2 nses/clin
All others 2 nses/clin
OT nurses Theatre duty

Full lists 13 nses/list
Part lists 10 nses/list
Casualty 2 nses/list
OPD nurses OPD duty 75 outpatients/day
CSSD 24 hours 10 nurses
Laboratory staff Performing tests

MLT Haematology 25 tests/day
Biochemistry 25 tests/day
Histology 15 tests/day
Bacteriology 25 tests/day
Clin pathology 25 tests/day
Parasitology 25 tests/day
Receiving samples 1.2 mins/test
Log, send results 2.4 mins/test
Allowances
Stocks and reordering 1 MLT continuously
Compiling statistics 1 MLT for 3 hrs/month
Night laboratory 1 MLT on duty every night
Labourer Number of MLTS required 1 labr/2 MLTs
Pharmacy staff / Pharmacist OPD 80 outpatients/day
Clinics 80 outpatients/day
112 ________________________________________________________________________________________
Inpatients 9,000 admissions/yr

X-ray staff / Radiographer Plain X-rays 40/day
Special techniques 30 mins/patient
Female labourer At least 1
Physiotherapy staff Treating patients 12 half-hour units/day

Physiotherapist
ECG staff / ECG recordist Ambulant patients 15 mins/patient
Ward patients 25 mins/patient
Allowance administration 1 recordist 4 hrs/week
Province hospitals
Ward nurses Surgical 3 occ. beds/nse
Medical 4 occ. beds/nse
Paediatric 3 occ. beds/nse
GYN/OBS 3 occ. beds/nse
Orthopaedic 2 occ. beds/nse
Psychiatric 3 occ. beds/nse
ENT 5 occ. beds/nse
Dermatology 8 occ. beds/nse
Antenatal 5 occ. beds/nse
Accident service 6 occ. beds/nse
ICU nurses ICU duty 5 nses/bed
Premature baby unit Prem baby duty 5 nses/cot
Labour room Deliveries 3 nses/available bed
Clinic nurses Clinic duty 1 nse/clinic, all types

_________________________________________________________________________________________ 113

CSSD 8 hours 8 nurses

Allowances
Stocks and reordering 1 MLT continuously
Compiling statistics 1 MLT for 3 hrs/month
Night laboratory 1 MLT on duty every night
Labourer Number of MLTs required 3 Labrs/7 MLTs
Pharmacy staff / Pharmacist OPD 40,000 outpatients/yr
Clinics 40,000 attendances/yr
Inpatients 13,750 admissions/yr
Allowances
Main store 2 pharms.
Surgical store 1 pharm
Relief 2 pharms

Physiotherapist
ECG staff
ECG recordist Ambulant patients 15 mins/patient
Allowance administration 1 recordist 4 hrs/week
114 ________________________________________________________________________________________
Base hospitals
Ward nurses Surgical 3 occ. beds/nse
Medical 5 occ. beds/nse
Paediatric 3 occ. beds/nse
GYN/OBS 3 occ. beds/nse
Labour room/maternity Deliveries 2 nses/available bed

nurses
Clinic nurses Clinic duty 1 nse/clinic all types

2 wings
1 wing 2 tables
OPD nurses OPD duty 75/day
CSSD (8 hours) 8 nurses

Allowances
Stocks and reordering 1 MLT 1 hour/day
Compiling statistics 1 MLT 3 hrs/month
Labourer No. MLTS required 1 Lbr/2 MLT
_________________________________________________________________________________________ 115
Inpatients 1/50 occ. beds
Allowance
Relief 2 pharms.
X-Ray staff / Radiographer Plain X-rays 40/day
Physiotherapy staff
Physiotherapist Treating patients 12 half-hour units/day
ECG staff
Allowance
Administration 1 recordist 4 hrs/week
District hospitals
Nursing staff Ward duties 5 beds/nse
Ward nurses
Labour room/maternity Deliveries 2 nses/available bed

nurses
Clinic nurses Clinics duty 1 nse/clinic, all types

Laboratory staff / MLT Performing tests 40 tests/day
116 ________________________________________________________________________________________

Allowances
Stocks and reordering 1 MLT 1 hour/day
Compiling statistics 1 MLT 3 hrs/month
Labourer 1 labourer/2 MLTs
Inpatients 1/50 occ. beds
Allowance: relief 2 pharms

Physiotherapist
ECG staff
Allowance
Administration 1 recordist 4 hrs/week
Consultant dental surgeons and associated staff in general hospitals,

provincial hospitals, base hospitals, dental institute
Consultant Trauma (dental, maxillo-facial)
Dental surgeons Conservative management 15 mins
Closed reduction 30-45 mins
Open reduction 30-45 mins
Management of residual deformities 30-45 mins
Infections (dental, oro-facial)

Conservative management 10 mins
Incision and drainage 10 mins
_________________________________________________________________________________________ 117

Decortication/sequestrotomy 30 mins
Segmental resections of jaw 3 hrs
Dento-alveolar surgery
Surgical removal of impacted
Teeth and retained roots 30 mins
Surgical endodontics 30 mins
Periodontal surgery 30 mins
Pre-prosthetic surgery 30 mins
Facial deformities
Cleft-lip and palate repair 1 hr
Jaw deformities 2 hrs
Ankylosis of TMJ 2 hrs
Syndromes 3 hrs
Cyst
Enucleation and packing 30 mins
Marsupialization and packing 30 mins
Neoplasm
Incisional biopsy 10 mins
Excision biopsy 45 mins
Flap procedure 2 hrs
Bone grafting 2 hrs
Salivary glands
Major 1.5 hrs
Minor 30 mins
Special investigations 15 mins
Malignant disease and reconstruction

Excision of jaw 5 hrs
Glossectomy 5 hrs
Excision of cheek/lips 5 hrs
Tracheostomy
Elective 30 mins
Emergency 10 mins
Extractions under general anaesthesia 30 mins

Non-surgical management
Oral mucosal diseases 15 mins
Bite raising applications 20 mins
Short wave diathermy 15 mins
Root canal therapy 20 mins
Splints 20 mins
Obturators/prosthesis 20 mins
118 ________________________________________________________________________________________
Ward activities
Ward rounds 2 mins/occ. bed
Clinical procedures 1 hr/day
Allowances
Clinical meetings 1.5 hrs/month
Unit management 2 hrs/month
Postgraduate training (dental institute only) 2 hrs/month
Senior house officers All consultant procedures are performed with assistance of one senior house officer except
allowances, so SHO Activity Standards are as given above.
House officers All consultant procedures are performed with assistance of one house officer except allowances,
so HO Activity Standards are as given above with the addition of:
Taking history 20 mins/admission
Preparing patients for surgery 20 mins/operation
Diagnosis card, medical certificate 15 mins/discharge
Dental surgeons and associated staff in

A* Teaching hospitals, general hospitals, provincial hospitals, base hospitals
B* District hospitals, peripheral units, central dispensaries, health centres, adolescent clinics,
prison hospitals, chest hospital
C* Dental institute
Staff category standard Component of workload Activity standard *

Dental surgeon Emergency
Extractions
Deciduous A,B 10 mins
Permanent
Caries A,B 10/hour
Periodontal A,B 10/hour
Other A,B 10/hour
D.A.A. treated A,B 5 mins

Fractures treated A,B 10 mins
Medico-legal A,B 15 mins
Post op.
Haemorrhage A,B 15 mins
Infections A,B 5 mins
Oral medicine
Pre-malignant
Leucoplakia A,B 5 mins
_________________________________________________________________________________________ 119
Staff category standard Component of workload Activity standard *

Others A,B 5 mins
Oral carcinoma A,B 5 mins
Candida albicans A,B 5 mins
Routine
Restorations
Temporary A,B 10 mins
Permanent
Amalgam A 15 mins
B 20 mins
Composite A 20 mins
B 25 mins
Advanced conservation A,B 20 mins
Periodontal
Scaling
Manual A,B 30 mins
Machine A 15 mins
Surgery A,B 30 mins
Surgery
Incisions & drainage A,B 15 mins
Impacted A,B 30 mins
Apicectomy A,B 30 mins
Fractures A,B 1 hour
Biopsies A,B 20 mins
Other A,B 30 mins
Referrals A,B 10 mins
All activities above C add 20% to B figures
Allowances
Health edn. talks to the community A,B,C 0.5 day/month
MOH monthly conference A,B,C 0.5 day/month
Recording & reporting A,B,C 10 mins/day +
30 mins/month
Maintaining stocks (1 person only) A,B,C 30 mins/month
Supervising, preventive maintenance
and cleaning A,B,C 1 hr/month
Nurses A 1/clinic
Trained attendants A,B,C 1/chair
120 ________________________________________________________________________________________
School dental clinics

Dental therapists Fillings
Deciduous 20 mins
Permanent 20 mins
Dressings
Deciduous 15 mins
Permanent 15 mins
Extractions 15 mins
Complete scaling 10-15 mins
Initial
Examination 10 mins
Complete 5 mins
Revision
Examination 5 mins
Complete 5 mins
Referral 5 mins
Health education session 20 mins
Outreach 2-3 days
Allowance
Supervisory visit 1 hour/month
Monthly MOH meeting 1 day/month
Recording & reporting 15 mins/day + 1 hour/month
Collecting salary 0.5 days/month
Inventory (1 person only) 1 hour/month
Labourer 1/clinic
Dental institute and all hospitals

Dental technicians Orthodontic plate 1 hour
Denture
Full 2 hours
Partial 1 hour
Obturator 1 hour
Crown 45 mins
Gunning splint 1 hour
Repairs 30 mins
Rebasing 30 mins
Relining 1 hour
Labourer 1/6 dental technicians
_________________________________________________________________________________________ 121
Activity standards (service standards and allowance standards) for MCH staff
Public health Inspections
Nursing sister PHMS 2.5 hours
SPHMS 2.5 hours
MCH clinics
Conducted 5.5 hours
Supervised 2.5 hours
School health
Medical inspections 11 mins
Follow up visits 5 mins
Investigations
Maternal deaths 2.5 hours
Infant deaths 25 mins
Senior public health midwife Inspections

PHMS 2.5 hours
Reports submitted 45 mins
MCH clinics
Assisted 3.5 hours
Supervised 3.5 hours
Homes visited
Supervision 25 mins
Investigation 22.5 mins
Public health midwife Registration

Eligible families 17.5 mins
Pregnant mothers 17.5 mins
Home visits to pregnant mothers

FVS - at risk 17.5mins
- normal 30 mins
SubseqVs - normal 20 mins
- at risk 25 mins
Natal care
Home deliveries - normal 6 hours
- at risk 9 hours
- abnormal 9 hours
Investigations
Still births 45 mins
Maternal deaths 3.5 hours
Infant deaths 1 hour
122 ________________________________________________________________________________________
Postnatal care: home visits

FVs 30 mins
SubseqVs 25 mins
Infant care: home visits

FVs 17.5 mins
SubseqVs 12.5 mins
Pre-school child care: home visits

FVs 12.5 mins
SubseqVs 10 mins
Family planning acceptors

Oral pill 12.5 mins
IUCD 12.5 mins
Injectable 12.5 mins
LRT 12.5 mins
Vasectomy 12.5 mins
Clinic activities
Pregnant - FVs 15 mins
- SubseqVs 12 mins
Infant - FVs 10 mins
- SubseqVs 10 mins
Pre-school - FVs 10 mins
- SubseqVs 10 mins
Time allowances for regular activities

The time allowances to be made for regular activities which are not directly covered by the service
statistics are of two types: standard allowances which are the same in all MOH areas (for
conferences, maintaining registers, etc.); and an allowance for travelling time between the base and
work locations during field activities. The amount of such time spent on travel depends on the size
and population density of the MOH area. Four types of area were identified, and the corresponding
time allowances for travel by each staff category are:
Type of area code PHNS SPHM PHM

Urban good UG 0.5 hr/day 0.5 hr/day 1 hr/day
Urban bad UB 1 hr/day 1 hr/day 1.75 hr/day
Rural good RG 1.5 hrs/day .5 hrs/day 2 hrs/day
Rural bad RB 2 hrs/day 2 hrs/day 3 hrs/day
Field activities are undertaken 14 days per month (averaged throughout the year).
_________________________________________________________________________________________ 123
The total time allowances, standard + travelling, for each staff category in each type of MOH area,
and the corresponding percentage allowances to be used in the WISN calculations are as follows:
Public health nursing sister

Staff conference: 1 day/month
Local conferences: 1 day/month
Maintain register of infant death )
Consolidate and forward area data ): 3 days/month
File and maintain records )
Educational programmes: 1 day/month
Travelling base to location of homes: UG/UB/RG/RB as above
Travelling between homes: 30 minutes/day
Allowances:
6 days/month = 6/19.7 = 30.5%
UB/UG/RG/RB = 0.5 to 2.0 x14x12/1,785 = 5.5%/11.0%/16.5%/22.0%
30 mins/day = 0.5x14x12/1,785 = 5.5%
Total allowance: UG 30.5%+5.5%+5.5% = 41.5%, say 42%

UB 30.5%+11%+5.5% = 47.0%
RG 30.5%+16.5%+5.5% = 52.5%, say 52%
RB 30.5%+22%+5.5% = 58.0%
Senior public health midwife

Ordering supplies: 1 day/month
Data returns: 7 days/qr
Staff conferences: 1 day/month
Other activities: 2 days/month
Travelling base to location of homes: UG/UB/RG/RB as above
Travelling between homes: 30 minutes/day
Allowances:
4 days/month + 7 days/qr = 76 days/year = 76/238 = 31.9%
UB/UG/RG/RB = 0.5 to 2.0 x14x12/1,785 = 5.5%/11.0%/16.5%/22.0%
0.5x14x12/1,785 = 5.5%
Total allowance: UG 31.9%+5.5%+5.5% = 42.9%, say 43%

UB 31.9%+11%+5.5% = 48.4%, say 48%
RG 31.9%+16.5%+5.5% = 53.9%, say 54%
RB 31.9%+22%+5.5% = 59.4%, say 59%
Public health midwife

Attending staff conference: 1.5 days/month
Collecting salary: 0.5 days/month
Assisting school health activities: 1 day/year
Recording and reporting )
Planning ) 1 hour/day +
Administration ) 0.5 day/month
Updating records and charts )
Travelling: UG/UB/RG/RB as above
124 ________________________________________________________________________________________
Allowances:
2.5 days/month = 2.5/20 = 12.5%
1 day/year = 1/240 = 0.4%
1 hour/day = 6/45 = 13.3%
UB/UG/RG/RB = 1 to 3 x14x12/1,785 = 9.3%/16.3%/18.7%/28.0%
Total allowance: UG 12.5%+0.4%+13.3%+9.3% = 35.5%, say 36%

UB 12.5%+0.4%+13.3%+16.3% = 42.5%, say 42%
RG 12.5%+0.4%+13.3%+18.7% = 44.9%, say 45%
RB 12.5%+0.4%+13.3%+28.0% = 54.2%, say 54%
_________________________________________________________________________________________ 125

A Manual For Implementation: Workload Indicators of Staffing Need (WISN)

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WHO/HRB/98.

Workload indicators of staffing need (WISN)

A manual for implementation

World Health Organization

Workload indicators of staffing need (WISN)

Prepared for the World Health Organization

World Health Organization

© World Health Organization

Section B – Steps in design and implementation of the method ...................................................... 23

Section C – Technical factors........................................................................................................... 37

Section D – Examples of WISN activity standards already used

The Manual is divided into four sections:

Section A – The WISN method and its uses

Section B – Steps in design and implementation of the method

Section C – Technical factors

1. The need for a new method

The WISN Method will produce all these types of results.

- simple to operate, using data which is already collected and available;

The WISN Method will meet all of these requirements.

2. The basis of the WISN Method

Workload in the facility (service statistics)

3. Features of the WISN Method

Province: Southern Highlands HC Nipa Year: 1986

Nursing officers ACTUAL

Community health workers ACTUAL

4. How the WISN Method works: differences and ratios

The difference, i.e. actual - calculated.

The ratio, i.e. actual/calculated.

5. Using the WISN Method: identifying priority situations

For example, compare the following two situations:

6. Using the WISN Method: improving the current staffing situation

Table 1 – Results for nursing staff in one health centre

From these results the health centre manager concluded:

d) which facilities should be considered first in these possible staff movements;

Table 2 – Example of a district summary

District 29 28 1.04 +1 39 44 0.89 -5

From these figures the district medical officer concluded:

The results show:

Table 3 – Equitable distribution of nursing aides

District 39 44 0.89 -5 39 44 0.89

Poor service quality and cost-effectiveness

7. Using the WISN Method: human resource management and planning

b) By inserting in the calculations new workload standards corresponding to improved

a) By inserting in the calculations the figures corresponding to changed conditions of

8. The constraints and limitations of the Method

1. Starting the process: setting the objectives

- the centre e.g.the Ministry of Health, and within that:

2. Choosing the basic design of the procedure to be implemented

1. Collecting the data to be used in the calculations.

3. Setting up the implementation group

The steering committee

The steering committee should consist of:

- representatives of the providers of the information: representatives of the MOH functional

The implementation manager

The task force

Administrative locus of the WISN implementation activity

Liaison between steering committee and task force

4. Procedure for establishing standards of professional performance

5. Mobilizing commitment to the WISN Method

6. Collecting and handling the data

Collecting the data

b) data on the actual staffing in health facilities: is it complete? up-to-date?

Producing the results